Declining cardiovascular mortality in England and Wales (2013-2024) masks persistent regional, sex, and age-based inequalities: a joinpoint analysis
H Awan, J Prashar, A Marla, J Bytyci, L Ng Fat, G Collett, A K GuptaAbstract
Background
Cardiovascular disease (CVD) mortality has declined since the millennium, but recent concerns suggest the COVID-19 pandemic may have adversely impacted these trends. Furthermore, it remains unclear whether nationwide trends mask underlying inequalities. We examined CVD mortality trends in England and Wales, stratified by age and sex, to identify disparities concealed within aggregate data.
Methods
Using Office for National Statistics (ONS) data from 2013 to 2024, we identified annual CVD deaths through standardized ICD-code definitions. Age-standardized death rates (ASDRs) were calculated using mid-year population estimates and direct age standardization using the 2013 European Standard Population in 5-year age bands up to ≥90 years. Standard errors were derived assuming a Poisson distribution of deaths. Log-linear joinpoint regression estimated annual percent change (APC) with 95% confidence intervals for all ages and adults aged ≥55 years, stratified by country and sex. Parallelism tests assessed whether trends differed significantly between subgroups.
Results
Between 2013 and 2024, ASDRs declined in both England (291 to 239 per 100,000; APC −1.47% per year, p<0.000001) and Wales (327 to 264 per 100,000; APC -1.46% per year, p<0.000001). Rates remained consistently higher in Wales throughout the study period, with no evidence of convergence. In both nations, females had lower ASDRs than males (England: 188 vs. 299 per 100,000; Wales: 212 vs. 327 per 100,000 in 2024). The declining trend among males stalled during 2019–2022, coinciding with the COVID-19 pandemic, with numerical increases (319 from 307) observed before resuming decline. However, since 2016 in Wales, males aged ≥55 years showed steady attenuation in mortality decline compared to females (non-parallel decline, p=0.044). Similarly, in England, among those ≥55 years, non-parallel declines between males and females were evident (all ages p=0.0002; ≥55 years p=0.002), indicating widening sex-based disparities in older populations.
Conclusions
Overall CVD mortality continues to decline in England and Wales, but this aggregate progress masks important inequalities. Wales maintains persistently higher mortality rates than England. In both countries, CVD mortality gains are unequal between sexes and age groups, with males and those aged ≥55 years experiencing attenuated improvements. The COVID-19 pandemic transiently and adversely impacted these vulnerable subgroups. These findings highlight that national-level progress obscures widening regional, age-, and sex-based disparities, necessitating targeted interventions to achieve equitable cardiovascular health outcomes.