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\begin{document}

\title{Ventricular Arrhythmia Mortality in Patients with Heart Failure in the
United States: Are There Differences Based on Race and Geography?}



\author[1]{Min Choon Tan}%
\author[2]{Yong Hao Yeo}%
\author[3]{Boon Jian San}%
\author[4]{Justin Lee Z}%
\author[5]{Kamala  Tamirisa }%
\author[6]{Yong-Mei Cha}%
\author[7]{Luis Scott}%
\author[7]{Dan Sorajja}%
\author[8]{Andrea Russo}%
\affil[1]{Saint Michael's Medical Center}%
\affil[2]{Corewell Health Beaumont Hospital}%
\affil[3]{AIMST University}%
\affil[4]{Cleveland Clinic}%
\affil[5]{Texas Cardiac Arrhythmia}%
\affil[6]{Mayo Clinic Minnesota}%
\affil[7]{Mayo Clinic Arizona}%
\affil[8]{Rowan University Cooper Medical School}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\textbf{Ventricular Arrhythmia Mortality in Patients with Heart Failure
in the United States: Are There Differences Based on Race and
Geography?}

Min Choon Tan MD\textsuperscript{1,2}, Yong Hao Yeo
MBBS\textsuperscript{3}, Boon Jian San MBBS\textsuperscript{4}, Justin
Z. Lee MD\textsuperscript{5}, Kamala Tamirisa MD\textsuperscript{6},
Yong-Mei Cha MD\textsuperscript{7}, Luis R. Scott MD\textsuperscript{2},
Dan Sorajja MD\textsuperscript{2}, Andrea M. Russo MD\textsuperscript{8}

\textsuperscript{1} Department of Internal Medicine, New York Medical
College at Saint Michael's Medical Center, Newark, NJ, USA

\textsuperscript{2} Department of Cardiovascular Medicine, Mayo Clinic,
Phoenix, AZ, USA

\textsuperscript{3} Department of Internal Medicine/Pediatrics, William
Beaumont University Hospital, Royal Oak, MI, USA

\textsuperscript{4} AIMST University, Malaysia

\textsuperscript{5} Department of Cardiovascular Medicine, Cleveland
Clinic, Cleveland, OH, USA

\textsuperscript{6} Texas Cardiac Arrhythmia, Dallas, TX, USA

\textsuperscript{7} Department of Cardiovascular Medicine, Mayo Clinic,
Rochester, MN, USA

\textsuperscript{8} Department of Cardiovascular Medicine, Cooper
University Health System/Cooper Medical School of Rowan University,
Camden, NJ, USA

Disclosures: All authors have no relationships relevant to the contents
of this paper to disclose.

Ethical approval: Not required

Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors

Word Count: 780

Corresponding author:

Andrea M. Russo MD

Department of Cardiovascular Medicine,

Cooper University Health System/Cooper Medical School of Rowan
University

1 Cooper Plaza,

Camden, New Jersey 08103

russo-andrea@cooperhealth.edu

The progression of heart failure (HF) is associated with detrimental
myocardial structural changes, predisposing HF patients to an increased
risk of ventricular arrhythmia (VA) events {[}1{]}. The evolving
landscape in HF management as well as innovative approaches to VA like
catheter ablation and neuromodulation, may impact morbidity and
mortality. However, real-world data assessing the VA-related mortality
trends among patients with HF remain scarce.

The Centers for Disease Control and Prevention's Wide-Ranging Online
Data for Epidemiologic

Research (CDC WONDER) is a publicly available online database containing
public health data, including mortality data. Death certificate data
from CDC WONDER were analyzed from 1999 to

2020 for VA-related mortality with comorbid HF among the U.S. population
aged [?] 25 years using

ICD-10 codes. Ventricular arrhythmias included ventricular tachycardia
(VT) (I47.2) and ventricular

fibrillation (VF) (I49.0) as the underlying primary cause of death.
Heart failure (I11.0, I13.0, I13.2,

I50) was stated as a contributing cause of death. Age-adjusted mortality
rates (AAMR) per 1,000,000

individuals were calculated by standardizing VA-related mortality with
comorbid HF to the 2000 U.S.

census population. The trends were determined over time by estimating
the annual percent change

(APC) using the Joinpoint regression program. Given the deidentified and
publicly available data,

institutional review board approval was not required.

Between 1999 and 2020, a total of 3,514 deaths related to VA with
comorbid HF were identified.

Overall, there was an increase in annual trends for the AAMR from 0.62
(95\% CI, 0.50 - 0.73) in

1999 to 1.06 (95\% CI, 0.94 - 1.19) in 2020, with an APC of 3.39 (95\%
CI, 2.07, 4.73) (\textbf{Central}

\textbf{Illustration)} .

When stratified by sex, cumulative AAMR was higher in males than females
(1.09 {[}95\% CI, 1.04-

1.13{]} vs. 0.49 {[}95\% CI, 0.47-0.52{]}). Both males and females had a
similar increase in AAMR over the

22 years; however, the AAPC was higher among males (4.30 {[}95\% CI,
2.88-5.74{]} vs. 1.64 {[}95\% CI,0.18-3.12{]}). When stratified by race,
African American individuals had the highest AAMR (1.24 {[}95\% CI,
1.14-1.35{]}), while the AAMR for White, Hispanic and Asian individuals
were 0.72 (95\% CI, 0.69-0.75), 0.40 (95\% CI, 0.33-0.47), and 0.23
(95\% CI, 0.16-0.32) respectively. The AAMR was higher in rural regions
than in urban regions (0.81 {[}95\% CI, 0.75-0.88{]} vs. 0.70 {[}95\%
CI, 0.68-0.73{]}). When AAMRs were compared between census regions of
the U.S., the South region had the highest AAMR (0.86 {[}95\% CI,
0.81-0.90{]}), followed by the Midwest (0.80 {[}95\% CI, 0.75-0.85{]}),
Northeast (0.62 {[}95\%CI, 0.57-0.67{]}), and West region (0.56 {[}95\%
CI, 0.51-0.61{]}).

This study provides crucial insight into VA-related mortality temporal
trends and disparities among patients with comorbid HF. Despite advances
in VA and HF management algorithms, our study revealed a 71\% increase
in AAMR in VA-related mortality with comorbid HF from 1999 to 2020. The
observed growth in AAMR could be attributed to the rising use of cardiac
implantable electronic devices, leading to increased recognition of VA
as a terminal event {[}2{]}. Alternatively, more effective emergency
medical services or greater availability of automatic external
defibrillators may help to identify VT or VF as the initial rhythm
recorded (rather than asystole or pulseless electrical activity). Our
study raises the hypothesis that more diligent management of VA,
including timely implantation of cardiac defibrillator devices and VT
ablation could have an impact on this population.

Our study demonstrates disparities in mortality trends, where American
Africans and rural regions

recorded higher AAMR. These may be potentially attributed to structural
racism, conscious and

unconscious biases, and the heightened socioeconomic challenges and
access to medical care, present

in rural areas {[}3{]}. Limited or delayed access to complex tertiary
care may impact mortality following

the occurrence of sustained VA. Patients who live in rural or
disadvantaged regions may not have

access to subspecialty referrals (such as electrophysiology or HF
specialists) and may have delayed or

limited access to primary prevention therapies such as implantable
cardioverter defibrillators or

cardiac resynchronization therapy that may otherwise favorably influence
outcomes. This highlights

the need to address the potential causes of these inequalities and
implement a focused policy that

incorporates the concept of social determinants of health to narrow the
gap.

There are several limitations in our study. First, due to the nature of
death certificate data, an accurate assessment of the cause of death
cannot be determined. Second, the database has no information at
individual levels, such as comorbidity, ejection fraction, duration of
diseases, and medical treatments, which are essential confounders for
mortality.

In conclusion, our study reveals an increase in VA-related mortality
with comorbid HF, with

disparities seen in African Americans and rural regions. It underscores
the pressing necessity for actions to facilitate the translation of
treatment advancements into tangible improvements in mortality outcomes
and healthcare inequalities.

\textbf{Central Illustration. The AAMR of Ventricular Arrythmias in
Heart Failure.}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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\end{figure}

\textbf{Reference}

1. Santangeli, P., et al., \emph{Management of Ventricular Arrhythmias
in Patients With Advanced Heart Failure.} J Am Coll Cardiol,
2017.\textbf{69} (14): p. 1842-1860.

2. Vaidya, V.R., et al., \emph{Trends in Cardiovascular Implantable
Electronic Device Insertion Between 1988 and 2018 in Olmsted
County.}JACC Clin Electrophysiol, 2022. \textbf{8} (1): p. 88-100.

3. Churchwell, K., et al., \emph{Call to Action: Structural Racism as a
Fundamental Driver of Health Disparities: A Presidential Advisory From
the American Heart Association.} Circulation, 2020. \textbf{142} (24):
p. e454-e468.

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