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More people living in rural areas of the United States are dying from heart attacks, strokes and other cardiovascular diseases – a trend that emerged after the start of the COVID-19 pandemic and appears to be driven by deaths among people under 65, a new study found.

Rural residents also continue to have higher cardiovascular death rates than their urban counterparts, according to the being presented Sunday at the ľ¹ÏÖ±²¥'s Scientific Sessions in Chicago.

The results underscore a "crisis" in rural America's cardiovascular health, said Dr. Lucas X. Marinacci, lead author of the study. They highlight the need to curb rural poverty, expand health insurance coverage in rural areas, and raise public awareness about the importance of preventing and managing obesity and diabetes – key drivers of cardiovascular disease, he said.

"I think this is kind of sounding the alarm," said Marinacci, a cardiology fellow at Beth Israel Deaconess Medical Center, a teaching hospital for Harvard Medical School in Boston.

Even before the pandemic, rural Americans were more likely to die from heart disease and stroke, in part due to high concentrations of poverty and higher rates of smoking, obesity and high blood pressure than among urban residents. Many residents in rural areas – who number about 66 million, according to – also have more trouble getting medical help and specialty care, whether because doctor's offices and hospitals may be farther away or because residents may lack transportation or health insurance, previous studies have shown.

"Nationally, obesity has been increasing among younger age groups, including children and adolescents," Marinacci said. "Rural areas may have been disproportionately affected by these trends."

Adults ages 40 to 59 have the , he said, which might have contributed to the increase in cardiovascular deaths among people ages 25 to 64.

Meanwhile, Marinacci said, the desire to avoid doctor's offices and hospitals during the pandemic led some people to defer testing and care for diabetes, high blood pressure and other risk factors. The pandemic-era surge in "diseases of despair" that can contribute to cardiovascular events – substance use, depression and suicidality – also hit rural communities harder, researchers said. Worsening heart health combined with psychosocial factors exacerbated by the pandemic may have made rural adults more susceptible to both the direct and indirect cardiovascular effects of COVID-19, they said.

The new study, simultaneously published in the Journal of the American College of Cardiology, analyzed federal death data of more than 11 million adults in the U.S. who died of heart attacks, strokes and other cardiovascular diseases between 2010 and 2022.

During the 2010s, cardiovascular death rates fell for everyone, regardless of where they lived. But after the onset of the pandemic in 2020, the trend reversed, leaving rural residents worse off in 2022 than in 2010. For them, cardiovascular deaths had increased by 3.4 deaths per 100,000 people, a relative increase of 0.8%. Meanwhile, the death rate had dropped by a relative 6.4% in urban areas, with nearly 24 fewer deaths per 100,000 people.

The disparity became even starker when researchers parsed death certificate data by age. By 2022, rural adults ages 25 to 64 had a 21% relative jump in cardiovascular death rates compared to 2010. That same age group in large metropolitan areas saw only a 3% relative increase.

By contrast, adults 65 and over fared better, as cardiovascular mortality rates saw a relative decline of 4.4% in rural areas and 8.5% in urban areas.

The study's limitations include the possibility of death certificates listing inaccurate causes of death. Researchers also only had information about where people lived at the time of their death, so it's unknown whether people had moved between rural and urban areas.

Dr. Bala Simon, deputy chief medical officer for the Arkansas Department of Health, said the findings reflect problems he sees regularly.

In Arkansas, a predominantly rural state where are overweight or have obesity, many people eat from fast food restaurants and gas station convenience stores because they're easier to reach than grocery stores that have fresh fruit and vegetables, he said.

Simon said the pandemic hit people under 65, who grew up in a fast-food culture since the 1960s, particularly hard.

"Cardiovascular disease doesn't happen overnight," said Simon, who was not involved in the new study. "It happens over decades."

The pandemic's toll on people in rural America, he said, shows the need to expand public health messaging. Reminding people to eat healthily, remain physically active and prioritize sleep would boost cardiovascular health, Simon said, while also providing better protection in a future pandemic.

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