Twenty-Five Years of Angina–Related Mortality in Elderly Adults Aged ≥ 65 Years: A Retrospective Cohort Study Using Real-World Data from the USA
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https://doi.org/10.71079/ASIDE.IM.110925248Abstract
Introduction: Angina is one of the ischemic heart diseases (IHD) that contributes to major cardiovascular complications up to death. We aim to assess angina-related mortality among adults aged ≥65 years in the U.S.
Methods: Nationwide mortality records were obtained from the CDC-WONDER database from 1999 to 2023 among U.S. adults aged ≥65 with angina. Age-adjusted mortality rates (AAMRs) were calculated per 100,000 population. Joinpoint regression analysis was utilized to evaluate average annual percent changes (AAPCs).
Results: From 1999 to 2023, a total of 36,544 deaths occurred among the elderly with angina in the U.S. The overall AAMR per 100,000 decreased from 7.52 in 1999 to 3.73 in 2023 (AAPC of -3.18; 95%CI: -3.79 to -2.75; p < 0.001). The AAMR for men decreased from 8.22 in 1999 to 4.75 in 2023 (AAPC of -2.53%; 95%CI: -3.02 to -2.09), and for women decreased from 6.95 in 1999 to 3.02 in 2023 (AAPC: -3.55%; 95%CI: -4.12 to -3.09). Across racial/ethnic groups, the highest overall rates were observed among NH-White individuals, 3.56. Overall, AAMRs were highest in the West, 4.00. The majority of deaths occurred in medical facilities (40.19%). Between 1999 and 2020, rural areas had a higher overall AAMR of 4.37 compared to urban areas, which had a rate of 3.02.
Conclusion: Trends in angina-related mortality declined from 1999 to 2023. Higher mortality rates were observed in men, rural areas, the West region, and among NH White individuals. Our findings indicated that these categories require targeted interventions to reduce mortality.
Keywords:
Angina, Trends, Mortality, Ischemic heart disease (IHD), CardiovascularReferences
1. Joshi PH, de Lemos JA. Diagnosis and Management of Stable Angina: A Review. JAMA. 2021: 1765 [PMID: 33944871, https://doi.org/10.1001/jama.2021.1527] DOI: https://doi.org/10.1001/jama.2021.1527
2. Kloner RA, Chaitman B. Angina and Its Management. J Cardiovasc Pharmacol Ther. 2017: 199 [PMID: 28196437, https://doi.org/10.1177/1074248416679733] DOI: https://doi.org/10.1177/1074248416679733
3. Agho AV, Disu F, Figueroa AS, Wiredu B, Okorigba EM, Olanite M, Okobi OE, Noman T. Prevalence of Angina Pectoris: An Analysis of the National Health Interview Survey (NHIS) Database. Cureus. 2025: e83076 [PMID: 40438860, https://doi.org/10.7759/cureus.83076] DOI: https://doi.org/10.7759/cureus.83076
4. Blumenthal DM, Howard SE, Searl Como J, O'Keefe SM, Atlas SJ, Horn DM, Wagle NW, Wasfy JH, Yeh RW, Metlay JP. Prevalence of Angina Among Primary Care Patients With Coronary Artery Disease. JAMA Netw Open. 2021: e2112800 [PMID: 34097047, https://doi.org/10.1001/jamanetworkopen.2021.12800] DOI: https://doi.org/10.1001/jamanetworkopen.2021.12800
5. Arnold SV, Grodzinsky A, Gosch KL, Kosiborod M, Jones PG, Breeding T, Towheed A, Beltrame J, Alexander KP, Spertus JA. Predictors of Physician Under-Recognition of Angina in Outpatients With Stable Coronary Artery Disease. Circ Cardiovasc Qual Outcomes. 2016: 554 [PMID: 27531922, https://doi.org/10.1161/CIRCOUTCOMES.116.002781] DOI: https://doi.org/10.1161/CIRCOUTCOMES.116.002781
6. Mehta PK, Huang J, Levit RD, Malas W, Waheed N, Bairey Merz CN. Ischemia and no obstructive coronary arteries (INOCA): A narrative review. Atherosclerosis. 2022: 8 [PMID: 36423427, https://doi.org/10.1016/j.atherosclerosis.2022.11.009] DOI: https://doi.org/10.1016/j.atherosclerosis.2022.11.009
7. Reynolds HR, Bairey Merz CN, Berry C, Samuel R, Saw J, Smilowitz NR, de Souza A, Sykes R, Taqueti VR, Wei J. Coronary Arterial Function and Disease in Women With No Obstructive Coronary Arteries. Circ Res. 2022: 529 [PMID: 35175840, https://doi.org/10.1161/CIRCRESAHA.121.319892] DOI: https://doi.org/10.1161/CIRCRESAHA.121.319892
8. Nanna MG, Wang SY, Damluji AA. Management of Stable Angina in the Older Adult Population. Circ Cardiovasc Interv. 2023: e012438 [PMID: 36916288, https://doi.org/10.1161/CIRCINTERVENTIONS.122.012438] DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.122.012438
9. Woodruff RC, Tong X, Khan SS, Shah NS, Jackson SL, Loustalot F, Vaughan AS. Trends in Cardiovascular Disease Mortality Rates and Excess Deaths, 2010-2022. Am J Prev Med. 2024: 582 [PMID: 37972797, https://doi.org/10.1016/j.amepre.2023.11.009] DOI: https://doi.org/10.1016/j.amepre.2023.11.009
10. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW, American Heart Association Council on E, Prevention Statistics C, Stroke Statistics S. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021: e254 [PMID: 33501848, https://doi.org/10.1161/CIR.0000000000000950] DOI: https://doi.org/10.1161/CIR.0000000000000950
11. Wadhera RK, Shen C, Gondi S, Chen S, Kazi DS, Yeh RW. Cardiovascular Deaths During the COVID-19 Pandemic in the United States. J Am Coll Cardiol. 2021: 159 [PMID: 33446309, https://doi.org/10.1016/j.jacc.2020.10.055] DOI: https://doi.org/10.1016/j.jacc.2020.10.055
12. Latif F, Nasir MM, Rehman WU, Hamza M, Mattumpuram J, Meer KK, Silvet H, Yarkoni A, Sabouni MA, Braiteh N, Patel K, Nashwan AJ. Demographics and regional trends of ischemic heart disease-related mortality in older adults in the United States, 1999-2020. PLoS One. 2025: e0318073 [PMID: 39854527, https://doi.org/10.1371/journal.pone.0318073] DOI: https://doi.org/10.1371/journal.pone.0318073
13. Maniya MT, Siddiqi AK, Shahzad M, Ali KM, Chachar MA, Amin SB, Garcia M, Naeem M. Rising atherosclerotic cardiovascular disease-related mortality among older adults in the United States: A 22-year retrospective cohort study using the CDC WONDER database. Hellenic J Cardiol. 2025: [PMID: 40701437, https://doi.org/10.1016/j.hjc.2025.06.001] DOI: https://doi.org/10.1016/j.hjc.2025.06.001
14. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008: 344 [PMID: 18313558, https://doi.org/10.1016/j.jclinepi.2007.11.008] DOI: https://doi.org/10.1016/j.jclinepi.2007.11.008
15. Aggarwal R, Chiu N, Loccoh EC, Kazi DS, Yeh RW, Wadhera RK. Rural-Urban Disparities: Diabetes, Hypertension, Heart Disease, and Stroke Mortality Among Black and White Adults, 1999-2018. J Am Coll Cardiol. 2021: 1480 [PMID: 33736831, https://doi.org/10.1016/j.jacc.2021.01.032] DOI: https://doi.org/10.1016/j.jacc.2021.01.032
16. Ingram DD, Franco SJ. 2013 NCHS Urban-Rural Classification Scheme for Counties. Vital Health Stat 2. 2014: 1 [PMID: 24776070,
17. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep. 1998: 1 [PMID: 9796247,
18. Hemida MF, Khan A, Ibrahim AA, Goel A, Patel K, Shahriar Z, Hageen AW, Alsaadi M, Rahman SU, Arafa A, Kholeif Z, Bahnasy A. Trends in Mortality from Leukemia and Ischemic Heart Disease: A 22-Year Analysis in the U.S. (1999-2020). ASIDE Internal Medicine. 2025: 21 https://doi.org/10.71079/aside.Im.091425163] DOI: https://doi.org/10.71079/ASIDE.IM.091425163
19. Ibrahim AA, Hemida MF, Hussein M, Saghir M, Faisal MR, Kritika FNU, Patel K, Ali A, Saghir E, Tablawy M, Mohamed AH, Arafa A. Disparities and Trends in Polycythemia Vera–Related Mortality in U.S. Adults Aged ≥45 Years from 1999 to 2023. ASIDE Internal Medicine. 2025: 24 https://doi.org/10.71079/aside.Im.092725233] DOI: https://doi.org/10.71079/ASIDE.IM.092725233
20. Sr P. Joinpoint Regression Program. Joinpoint Trend Analysis Software [Internet]. 2025.
21. Braunwald E. Cardiology: A Century of Progress. Circulation. 2024: 78 [PMID: 38190446, https://doi.org/10.1161/CIRCULATIONAHA.123.064458] DOI: https://doi.org/10.1161/CIRCULATIONAHA.123.064458
22. Prasad A. Ischemic Heart Disease. 2010 [cited 10/25/2025]. In: Mayo Clinic Internal Medicine Board Review [Internet]: Oxford University Press, [cited 10/25/2025]; [0]. Available from: https://doi.org/10.1093/med/9780199755691.003.0045. DOI: https://doi.org/10.1093/med/9780199755691.003.0045
23. Centers for Disease C, Prevention. Heart disease prevalence - health, United States.
24. Liu M, Aggarwal R, Zheng Z, Yeh RW, Kazi DS, Joynt Maddox KE, Wadhera RK. Cardiovascular Health of Middle-Aged U.S. Adults by Income Level, 1999 to March 2020 : A Serial Cross-Sectional Study. Ann Intern Med. 2023: 1595 [PMID: 37983825, https://doi.org/10.7326/M23-2109] DOI: https://doi.org/10.7326/M23-2109
25. Wall HK, Ritchey MD, Gillespie C, Omura JD, Jamal A, George MG. Vital Signs: Prevalence of Key Cardiovascular Disease Risk Factors for Million Hearts 2022 - United States, 2011-2016. MMWR Morb Mortal Wkly Rep. 2018: 983 [PMID: 30188885, https://doi.org/10.15585/mmwr.mm6735a4] DOI: https://doi.org/10.15585/mmwr.mm6735a4
26. Hausvater A, Anthopolos R, Seltzer A, Spruill T, Peteiro J, Lopez-sendon J, Celutkiene J, Sidhu M, Demchenko E, Beleslin B, Kedev S, Grodzinsky A, Spertus J, Fleg J, Maron D, Hochman J, Reynolds H. Abstract 4147235: Sex Differences in Psychosocial Factors and Angina in Patients with Chronic Coronary Disease. Circulation. 2024: https://doi.org/10.1161/circ.150.suppl_1.4147235] DOI: https://doi.org/10.1161/circ.150.suppl_1.4147235
27. Wenger N. Women and Coronary Heart Disease: A Century after Herrick; Understudied, Underdiagnosed, and Undertreated. Circulation. 2011: https://doi.org/10.1161/circ.124.suppl_21.A612] DOI: https://doi.org/10.1161/circ.124.suppl_21.A612
28. Wenger N. Tailoring cardiovascular risk assessment and prevention for women: One size does not fit all. Glob Cardiol Sci Pract. 2017: e201701 [PMID: 28971101, https://doi.org/10.21542/gcsp.2017.1] DOI: https://doi.org/10.21542/gcsp.2017.1
29. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, Lindley KJ, Vaccarino V, Wang TY, Watson KE, Wenger NK, American Heart Association Cardiovascular Disease in W, Special Populations Committee of the Council on Clinical Cardiology CoE, Prevention CoC, Stroke N, Council on Quality of C, Outcomes R. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016: 916 [PMID: 26811316, https://doi.org/10.1161/CIR.0000000000000351] DOI: https://doi.org/10.1161/CIR.0000000000000351
30. He J, Bundy JD, Geng S, Tian L, He H, Li X, Ferdinand KC, Anderson AH, Dorans KS, Vasan RS, Mills KT, Chen J. Social, Behavioral, and Metabolic Risk Factors and Racial Disparities in Cardiovascular Disease Mortality in U.S. Adults : An Observational Study. Ann Intern Med. 2023: 1200 [PMID: 37579311, https://doi.org/10.7326/M23-0507] DOI: https://doi.org/10.7326/M23-0507
31. Coronado F, Melvin SC, Bell RA, Zhao G. Global Responses to Prevent, Manage, and Control Cardiovascular Diseases. Prev Chronic Dis. 2022: E84 [PMID: 36480801, https://doi.org/10.5888/pcd19.220347] DOI: https://doi.org/10.5888/pcd19.220347
32. Kyalwazi AN, Loccoh EC, Brewer LC, Ofili EO, Xu J, Song Y, Joynt Maddox KE, Yeh RW, Wadhera RK. Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019. Circulation. 2022: 211 [PMID: 35861764, https://doi.org/10.1161/CIRCULATIONAHA.122.060199] DOI: https://doi.org/10.1161/CIRCULATIONAHA.122.060199
33. Obi K, Effron MB. Racial Disparities and Excess Cardiovascular Mortality Before and During the COVID-19 Pandemic: Time for a Solution. Mayo Clin Proc. 2022: 2180 [PMID: 36464458, https://doi.org/10.1016/j.mayocp.2022.10.015] DOI: https://doi.org/10.1016/j.mayocp.2022.10.015
34. Janus SE, Makhlouf M, Chahine N, Motairek I, Al-Kindi SG. Examining Disparities and Excess Cardiovascular Mortality Before and During the COVID-19 Pandemic. Mayo Clin Proc. 2022: 2206 [PMID: 36336516, https://doi.org/10.1016/j.mayocp.2022.07.008] DOI: https://doi.org/10.1016/j.mayocp.2022.07.008
35. Sekkarie A, Woodruff RC, Casper M, Paul AT, Vaughan AS. Rural-urban disparities in cardiovascular disease mortality vary by poverty level and region. J Rural Health. 2025: e12874 [PMID: 39152622, https://doi.org/10.1111/jrh.12874] DOI: https://doi.org/10.1111/jrh.12874
36. Kulshreshtha A, Goyal A, Dabhadkar K, Veledar E, Vaccarino V. Urban-rural differences in coronary heart disease mortality in the United States: 1999-2009. Public Health Rep. 2014: 19 [PMID: 24381356, https://doi.org/10.1177/003335491412900105] DOI: https://doi.org/10.1177/003335491412900105
37. Ritchey MD, Wall HK, Owens PL, Wright JS. Vital Signs: State-Level Variation in Nonfatal and Fatal Cardiovascular Events Targeted for Prevention by Million Hearts 2022. MMWR Morb Mortal Wkly Rep. 2018: 974 [PMID: 30188881, https://doi.org/10.15585/mmwr.mm6735a3] DOI: https://doi.org/10.15585/mmwr.mm6735a3
38. Bairey Merz CN, Pepine CJ, Walsh MN, Fleg JL. Ischemia and No Obstructive Coronary Artery Disease (INOCA): Developing Evidence-Based Therapies and Research Agenda for the Next Decade. Circulation. 2017: 1075 [PMID: 28289007, https://doi.org/10.1161/CIRCULATIONAHA.116.024534] DOI: https://doi.org/10.1161/CIRCULATIONAHA.116.024534
39. Faheem MSB, Fatima Y, Munir SU, Khabir M, Khatri N. Trends in ischemic heart disease and thromboembolism-related mortality in the United States, 1999-2024: A population-based analysis using CDC WONDER Data. Thromb Res. 2025: 109482 [PMID: 40987074, https://doi.org/10.1016/j.thromres.2025.109482] DOI: https://doi.org/10.1016/j.thromres.2025.109482
40. McLeod K, Thielen S, Mosley B, Sevick C, Khazanie P. Resource Utilization For Medicare Beneficiaries With Heart Failure At The End Of Life. Journal of Cardiac Failure. 2024: https://doi.org/10.1016/j.cardfail.2023.10.446] DOI: https://doi.org/10.1016/j.cardfail.2023.10.446
41. Chuzi S, Molsberry R, Ogunseitan A, Warraich HJ, Wilcox JE, Grady KL, Yancy CW, Khan SS. Trends in Place of Death for Cardiovascular Mortality Related to Heart Failure in the United States From 2003 to 2017. Circ Heart Fail. 2020: e006587 [PMID: 32059627, https://doi.org/10.1161/CIRCHEARTFAILURE.119.006587] DOI: https://doi.org/10.1161/CIRCHEARTFAILURE.119.006587
42. Warraich H, Kaufman BG, Cross SH. Trends and Factors Associated with Place of Death among Individuals with Cardiovascular Disease in the United States. Innovation in Aging. 2019: S132 https://doi.org/10.1093/geroni/igz038.482] DOI: https://doi.org/10.1093/geroni/igz038.482
43. Merriel SWD. Management of angina in primary care. Nurse Prescribing. 2017: 492 https://doi.org/10.12968/npre.2017.15.10.492] DOI: https://doi.org/10.12968/npre.2017.15.10.492
44. Banerjee A. Stable coronary disease: Cinderella must go to the ball. Eur Heart J Qual Care Clin Outcomes. 2016: 151 [PMID: 29474614, https://doi.org/10.1093/ehjqcco/qcw022] DOI: https://doi.org/10.1093/ehjqcco/qcw022
45. Leucker TM, Schulman SP, Gerstenblith G. Stable ischemic heart disease: how to keep it that way. J Clin Invest. 2020: 1055 [PMID: 31985489, https://doi.org/10.1172/JCI135959] DOI: https://doi.org/10.1172/JCI135959
46. Ahmed M, Javaid H, Shafiq A, Nadeem ZA, Ahsan A, Nofal A, Ahmed R, Alam M, Fudim M, Fonarow GC, Mamas MA. Trends and Disparities in Coronary Artery Disease and Obesity-Related Mortality in the United States From 1999-2022. Endocrinol Diabetes Metab. 2024: e70010 [PMID: 39462250, https://doi.org/10.1002/edm2.70010] DOI: https://doi.org/10.1002/edm2.70010
47. Guan C, Wu S, Xu W, Zhang J. Global, regional, and national burden of ischaemic heart disease and its trends, 1990-2019. Public Health. 2023: 57 [PMID: 37604031, https://doi.org/10.1016/j.puhe.2023.07.010] DOI: https://doi.org/10.1016/j.puhe.2023.07.010
48. Marchionni N, Orso F. Stable angina in the elderly: diagnostic and therapeutic approach. J Cardiovasc Med (Hagerstown). 2018: e84 [PMID: 29538150, https://doi.org/10.2459/JCM.0000000000000603] DOI: https://doi.org/10.2459/JCM.0000000000000603
49. Paquin A, Bastiany A, Piche ME. The Complexity of Racial and Ethnic Disparities in Cardiovascular Health: A Role for Underrepresented Populations-Focused Clinics? Can J Cardiol. 2023: 1667 [PMID: 37897474, https://doi.org/10.1016/j.cjca.2023.09.016] DOI: https://doi.org/10.1016/j.cjca.2023.09.016
50. Wenger NK. The Feminine Face of Heart Disease 2024. Circulation. 2024: 489 [PMID: 38346107, https://doi.org/10.1161/CIRCULATIONAHA.123.064460] DOI: https://doi.org/10.1161/CIRCULATIONAHA.123.064460
51. Sanchez JM, Marcus GM. American Indians and atrial fibrillation. Heart Rhythm O2. 2022: 760 [PMID: 36588996, https://doi.org/10.1016/j.hroo.2022.08.010] DOI: https://doi.org/10.1016/j.hroo.2022.08.010
52. Kershaw KN, Khan SS. Moving Beyond the Individual: Multilevel Solutions for Equitable Hypertension Control. Circ Cardiovasc Qual Outcomes. 2022: e009374 [PMID: 36065816, https://doi.org/10.1161/CIRCOUTCOMES.122.009374] DOI: https://doi.org/10.1161/CIRCOUTCOMES.122.009374
Data Availability Statement
The data that support the findings of this study are openly available in CDC‐WONDER at https://wonder.cdc.gov. The data supporting the findings of this study were obtained from the CDC WONDER online database (Centers for Disease Control and Prevention Wide‐ranging Online Data for Epidemiologic Research). Further inquiries can be directed to the corresponding author.
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Copyright (c) 2025 Mohamed Fawzi Hemida, Alyaa Ahmed Ibrahim, Anika Goel, Mirna Hussein, Krish Patel, Muhammad Raza Sarfraz, Omar Y. Alkasabrah, MD, Maryam Saghir, Komal Karmani, Eshal Saghir, Zahin Shahriar, Safeya Fawzi, Ahmed Bahnasy, Muhammad Faizan Ali, Amro Ali, Ahmad M. Abdelkhalek, Raheel Ahmed, MBBS, MRCP, PhD
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- Received
- 4 Sep 2025
- Received in revised form
- 19 Oct 2025
- Accepted
- 22 Oct 2025
- Published
- 9 Nov 2025
