Time trends in mortality from heart failure and atherosclerotic cardiovascular disease in people with and without diabetes: a multi-national population-based study

Background — Contemporary trends in cardiovascular disease (CVD) cause-specific mortality by diabetes status are inadequately described. We examined trends by diabetes status in coronary heart disease (CHD), cerebrovascular disease, and heart failure mortality, and mortality rate ratios (people with diabetes versus those without diabetes) across nine high-income jurisdictions.

Methods — We assembled CVD cause-specific mortality data from nine administrative datasets (Europe [n=5], Australia [n=1], Canada [n=2], and South Korea [n=1]), spanning 2000–23. Using Poisson regression, we estimated mortality rates by diabetes status and mortality rate ratios.

Findings — There were 2·92 million CVD deaths over 1·30 billion person-years of follow-up. In all jurisdictions and in both people with and without diabetes, the total CVD and CHD mortality rates fell across the observed time period. The 5-year percent changes in CHD mortality ranged from −11·5% to −32·3%. Reductions in heart failure mortality were smaller than those for CHD mortality (except in Scotland) and smaller than those for cerebrovascular mortality (except in Scotland and Denmark). Heart failure mortality increased in Ontario, Canada. The excess CHD mortality associated with diabetes (mortality rate ratio ~2·0) fell in three of nine jurisdictions and was stable or uncertain in the remainder. No jurisdiction had a fall in excess heart failure mortality associated with diabetes.

Interpretation — Declines in heart failure mortality in both people with and without diabetes were less marked than were declines in CHD and cerebrovascular disease mortality in most jurisdictions. Heart failure mortality rate ratios have not decreased. A greater focus on reducing heart failure mortality in people with and without diabetes might be required.