Heart disease remains the number one cause of death in the United States, but new research from Washington University in St. Louis reveals that not all communities are sharing equally in recent improvements. While national cardiovascular death rates have generally moved downward over the past few decades, the gap between the best- and worst-off areas is expanding. The findings highlight growing inequalities driven by geography, race, income, and access to care-raising urgent concerns about who truly benefits from modern advances in heart health and who continues to be left behind.
Widening heart disease inequities across US communities
The Washington University analysis paints a detailed picture of how cardiovascular health has diverged across the country. Using several decades of national data, the research team identified clear clusters of counties where people face substantially higher odds of dying from heart disease than residents in better-resourced areas-even though they live under the same national guidelines, insurance frameworks, and medical breakthroughs.
Rural pockets of the South, stretches of Appalachia, and portions of the Midwest appear as stubborn “hotspots” where progress has stalled or even reversed. In contrast, certain large metropolitan areas have recorded substantial declines in heart disease mortality. This uneven progress, according to the investigators, reflects structural patterns built into the social and economic fabric of communities rather than random variation.
These communities with stagnant or worsening cardiovascular outcomes tend to share a familiar and overlapping set of risk conditions:
- Reduced access to affordable primary care and cardiology services
- Elevated rates of hypertension, diabetes, and obesity
- Long-term financial hardship, including job instability and housing insecurity
- Scarcity of nutritious foods and safe, well-maintained spaces for exercise
- Decades of underfunding in local public health systems and prevention initiatives
This pattern reflects national trends: according to provisional data from the CDC, heart disease accounted for more than 690,000 deaths in 2023, with rates significantly higher in many rural and low-income counties compared to wealthier, urban ones.
| Community Type | Heart Disease Trend | Primary Warning Signal |
|---|---|---|
| Rural Southern counties | Rates increasing | Uncontrolled hypertension |
| Post-industrial Midwest | Leveling off | Economic volatility |
| Major metropolitan centers | Rates decreasing | Greater reach of preventive care |
| Suburban corridors | Mixed patterns | Lifestyle- and behavior-related risks |
How social determinants drive cardiovascular risk
Drawing on nationwide health surveys, electronic health records, and demographic data, Washington University researchers conclude that “social determinants of health” are central to understanding today’s heart disease burden. Instead of genetics alone shaping outcomes, the study shows that daily living conditions-such as income stability, neighborhood safety, and transportation access-directly influence when and how heart disease develops.
Residents of neighborhoods facing persistent disinvestment often experience a layering of stressors: unstable housing, lack of nearby grocery stores with fresh produce, long commutes or limited public transit, and fewer health care options. Over time, this accumulation contributes to earlier onset of high blood pressure, diabetes, and heart failure, as well as more severe complications. These patterns frequently line up with racial and ethnic segregation, meaning that cardiovascular risk can often be predicted by a ZIP code.
The researchers identified several social and environmental factors that strongly correlate with higher rates of heart attacks, strokes, and heart failure-factors that traditional risk calculators and clinical guidelines typically overlook:
- Ongoing financial stress that leads to missed follow-up visits and delayed prescription refills
- Precarious employment and lapses in insurance that interrupt continuous care
- Lack of safe, accessible outdoor spaces for walking, biking, or recreation, especially in dense urban areas
- Exposure to air pollution from nearby highways, refineries, or industrial zones
- Chronic discrimination and psychosocial stress that drive higher blood pressure and systemic inflammation
| Community Factor | Observed Impact on Heart Health |
|---|---|
| Low density of clinics and practitioners | Greater reliance on emergency departments for routine care |
| Food deserts and poor food access | Higher prevalence of obesity and type 2 diabetes |
| Widespread home foreclosures and housing instability | Sharp increases in stress-related cardiac admissions |
Mapping heart disease hotspots across the country
When the researchers layered county-level heart disease data over indicators such as hospital closures, clinic density, and local economic conditions, clear hotspots emerged. In many rural Southern counties, Appalachian communities, and tribal regions, people often must travel long distances for specialty cardiac care, sometimes more than an hour each way. Limited public transit, unreliable vehicles, and patchy broadband access further complicate both in-person and telehealth visits.
These barriers intensify everyday financial and health pressures: medical bills that pile up, unstable employment, and prescription drug costs that outpace wages. In such settings, elevated blood pressure, high cholesterol, and diabetes frequently remain undiagnosed or untreated until a crisis-like a heart attack or stroke-forces an emergency visit. Even after such events, insurance coverage may not fully support cardiac rehabilitation, follow-up monitoring, or medications, widening the recovery gap between patients in high-resource and low-resource areas.
The study also shows that economic distress within a state can predict heart disease patterns from one county to the next. Counties marked by chronic poverty, crumbling infrastructure, limited job opportunities, and aging housing stock tend to have higher rates of heart-related hospitalizations and deaths than wealthier neighboring counties.
Key contributors to this uneven burden include:
- Health care deserts with minimal or no local cardiology services
- Low household incomes that limit access to regular checkups, medications, and healthy food
- Food insecurity and dependence on inexpensive, highly processed products
- Relentless financial strain that accelerates underlying cardiovascular risk factors
| County Type | Clinic Density* | Heart Disease Deaths |
|---|---|---|
| Urban, high income | High | Lower |
| Rural, high poverty | Low | Higher |
| Small metro, mixed income | Moderate | Moderate |
*Clinics per 10,000 residents; heart disease deaths shown as relative comparisons within the regions analyzed.
Policy, prevention, and the need to focus on high-risk neighborhoods
Public health experts at Washington University argue that the evidence clearly points beyond individual behavior to broader policy decisions. Choices about where to build clinics, how to fund prevention programs, and which communities receive infrastructure investments are shaping who survives heart disease-and who does not.
They advocate for zip code-level prevention strategies that prioritize neighborhoods where cardiac hospitalizations and early deaths are climbing fastest. Rather than one-size-fits-all campaigns, they call for tailored approaches that recognize the specific barriers residents face, from lack of transportation to limited childcare.
Recommended strategies include scaling up early and frequent blood pressure and cholesterol screenings, expanding mobile health services in areas without nearby clinics, and forming partnerships with community organizations, faith groups, and local employers. Without intentionally redirecting resources to high-burden areas, they caution, cutting-edge cardiology treatments will continue to reach those who already have the most advantages.
Researchers and clinicians involved in the work outlined several practical priorities for local, state, and federal leaders:
- Deploy mobile screening units to workplaces, congregations, schools, and community centers in historically underfunded neighborhoods.
- Support affordable, heart-healthy food options through subsidies, incentives for grocery retailers, and support for local markets in food deserts.
- Invest in community health workers who can visit patients at home for blood pressure checks, medication counseling, and follow-up after hospitalizations.
- Offer incentives for primary care and cardiology practices to establish or expand clinics in census tracts with the highest cardiovascular mortality.
| Priority Area | Key Action | Intended Impact |
|---|---|---|
| Screening & Early Detection | Provide no-cost annual heart health checks | Identify high-risk individuals sooner |
| Neighborhood Investment | Fund new clinics, parks, and safe walking paths | Support healthier daily routines |
| Community Health Workforce | Train and employ local health workers | Improve continuity of care and follow-up |
Looking ahead: closing the cardiovascular equity gap
As researchers continue to track these trends, a clear message is emerging across the public health community: unless targeted, place-based strategies are put in place, the burden of heart disease will increasingly fall along predictable lines of race, neighborhood, and income.
The Washington University team plans to focus its next phase of work on identifying which local policies and clinical approaches most effectively reduce gaps in cardiovascular outcomes. That includes evaluating community-level interventions, from expanded Medicaid coverage to investments in housing, transportation, and food access.
For now, the authors argue, the data make one point unmistakable: achieving cardiovascular equity must move from a distant goal to an immediate priority for policymakers, health systems, and community leaders. The choices made in the coming years-about where to invest, whom to prioritize, and which barriers to remove-will shape not only who develops heart disease, but also who has the resources and opportunity to survive it.
