This retrospective analysis of mortality data from 1999 to 2023 identified key findings related to AA and AD-associated deaths. First, the overall AAMR exhibited a consistent downward trend, with the most rapid decline generally occurring between 2005 and 2011, followed by stabilization post-2021. Males consistently demonstrated a higher AAMR compared with females, with marked racial/ethnic disparities: NH-Black populations bore the greatest disease burden. Geographic disparities were also observed, with the Midwest region having the highest mortality rate. From 1999 to 2020, AAMR remained higher in Nonmetropolitan areas than in Metropolitan areas. Finally, age-stratified analysis revealed that the ≥ 85 years age group carried the highest disease burden, while the 35–44 years age group exhibited an upward trend in overall mortality (Table S7). Interpretation of subgroup-specific APCs should be cautious, as exploratory stratified analyses may carry a potential risk of type I error inflation without formal multiplicity correction.
Cigarette smoking and hypertension are the two most important modifiable risk factors for both AA and AD. Cigarette smoking accelerates elastic fiber degradation and vascular inflammation, while chronic elevation of blood pressure increases aortic wall stress and promotes medial degeneration, thereby playing a central role in AAA development and increasing the risk of AD [30,31,32]. Aging is strongly associated with aortic stiffening, atherosclerosis, and collagen remodeling, leading to sharply increased incidence and mortality of AA and AD [33, 34]. Male sex, dyslipidemia, and inherited connective tissue disorders further increase susceptibility [30, 35, 36]. Major complications include aneurysm rupture, thromboembolism, organ malperfusion, acute aortic regurgitation, stroke, and sudden death, all associated with high mortality [35].
Reducing the burden of AA and AD requires integrated preventive strategies. Strict blood pressure control is fundamental, as antihypertensive therapy lowers aortic wall stress and reduces disease progression and dissection risk [35]. Tobacco control is one of the most effective population-level interventions, with smoking cessation significantly decreasing AAA incidence and mortality [30]. Lifestyle modifications, including weight control, regular physical activity, and healthy diet, improve cardiometabolic profiles and reduce overall vascular risk; Targeted screening programs, particularly ultrasound screening for high-risk individuals, facilitate early detection and elective intervention, although current programs largely focus on older adults [36]. Pharmacologic therapy and timely surgical or endovascular repair remain essential for preventing catastrophic outcomes [35].
Between 1999 and 2023, the total number of AA and AD-related deaths increased, whereas the national AAMR exhibited an overall downward trend. First, this trend may be attributable to global tobacco control efforts, as smoking represents a modifiable risk factor [37]. Cigarette smoke has been shown to exacerbate atherosclerosis, leading to elastin fragmentation, aneurysm formation, rupture, and subsequent death [38]. Notably, tobacco control initiatives in the United States have been highly effective: the adult smoking rate decreased by 73%, from 42.6% in 1965 to 11.6% in 2022 [39]. Consistent with this, previous studies have demonstrated that the reduction in AA prevalence is concurrent with decreased cigarette and tobacco consumption, thereby reducing AA incidence at the population level [37]. Similarly, tobacco control measures have exerted a substantial protective effect on AD. Smoking may compromise aortic wall integrity by inducing endothelial dysfunction, exacerbating inflammatory responses, accelerating atherosclerosis, and elevating blood pressure, thereby increasing the risk of intimal tearing and dissection formation [31]. As adult smoking prevalence in the United States has declined markedly over recent decades, the burden of smoking-related vascular injury has decreased in parallel, which may contribute to a reduced population-level risk of AD and improved overall prognosis [40]. In addition, epidemiological evidence indicates that passive smoking is also associated with increased AD-related mortality, and that reductions in tobacco exposure are consistent with the long-term downward trend in AD mortality [41], supporting tobacco control as an important public health strategy for mitigating the burden of aortic dissection. Collectively, these findings indicate that sustained tobacco control efforts may have contributed substantially to the observed decline in age-adjusted mortality from both AA and AD among U.S. adults.
Second, advances in medical care and disease management have contributed, at least in part, to the observed decline in mortality. The introduction and widespread adoption of TEVAR have fundamentally transformed the treatment paradigm for type B aortic dissection and high-risk patients, leading to a substantial reduction in perioperative mortality [42, 43]. Concurrently, cross-sectional imaging modalities (computed tomography [CT], magnetic resonance imaging [MRI]) have become standard practice, enabling earlier and more accurate diagnosis even in atypical or incidental cases [44, 45]. These technological advancements have been complemented by the development of standardized care pathways and multidisciplinary “aortic teams,” which have optimized triage and intervention strategies [46]. Finally, the advancement of national cardiovascular disease screening and prevention policies in the United States has facilitated early detection and timely treatment, contributing to the observed trend.
Throughout the study period, significant gender disparities were observed, with males consistently maintaining a higher AAMR than females. First, this disparity is associated with the unique physiological characteristics of females. Estrogen has been shown to maintain aortic wall structural stability by inhibiting aortic smooth muscle cell apoptosis and reducing elastic fiber degradation (e.g., downregulating the activity of matrix metalloproteinase-9 [MMP-9]) [47]. On the other hand, risk exposure factors indicate that high-risk behaviors are more concentrated in males: first, the smoking rate among males (14.8% in males vs. 11.2% in females in 2020) is higher than that in females [48];second, males in the United States are more likely to have hypertension than females, while a higher proportion of females are aware of their hypertension diagnosis, have received treatment, and achieved hypertension control [49]. Additionally, females are generally more likely to seek medical care than males [50]. Finally, it is noteworthy that AAA are less common in females, they face a higher risk of aneurysm rupture and mortality than males with aneurysms of similar size [51].
In addition to AA, pronounced sex-based differences have also been observed in AD. Estrogen has protective effects on vascular biology, including anti-inflammatory actions, improved endothelial function, and reduced extracellular matrix degradation, which are believed to contribute to lower AD susceptibility in females [52]. Females generally present with AD at older ages than males, consistent with a later loss of estrogen’s vascular protection and later onset of hypertension and vascular stiffness. In contrast, male vascular biology and hemodynamic profiles—such as greater aortic wall shear stress and higher prevalence of uncontrolled hypertension—are associated with increased mechanical stress on the aortic wall and greater propensity for intimal tearing. These biological and hemodynamic differences, along with sex-specific risk factor profiles, likely contribute to the observed higher incidence of AD in men [53].
Our study revealed that age-stratified analysis aligned with the trend of higher mortality in older age groups alongside an overall downward trajectory. First, both AA and AD are typical age-related vascular diseases, with their incidence and mortality risks increasing exponentially with age [54]. This may be attributed to the high prevalence of comorbidities (e.g., hypertension, dyslipidemia, atherosclerosis) in this population, coupled with comprehensive physical function decline that precludes tolerance of surgical intervention. Furthermore, the 35–44 years age group exhibited an upward mortality trend, indicating an emerging younger-onset pattern of the disease. First, recent U.S. data demonstrate that the prevalence of hypertension in the 35–44 years age group increased from 12% in 2000 to 22% in 2023 [55]; long-term uncontrolled hypertension in young and middle-aged adults accelerates aortic wall injury, induces early-onset aortic dissection, and such patients exhibit faster progression of dissection rupture with higher mortality [56, 57]. Second, among U.S. adults aged 35–44 years, approximately 23.9% are current smokers, 27.4% engage in insufficient physical activity, and 44.4% report averaging ≤ 6 h of sleep per day [58]. Additionally, excessive alcohol consumption (e.g., binge drinking) is common in younger adults, affecting roughly 17–20% [59]. These lifestyle risk factors are strongly associated with increased cardiovascular and hypertension risk. Finally, existing aortic disease screening programs in the United States primarily target older populations, with nearly no age-specific screening available for the 35–44 years cohort [60]. The increasing prevalence of hypertension among younger adults and unhealthy lifestyle habits have emerged as potential contributors to the development and progression of AA and AD.
Additionally, stimulant use, including cocaine and amphetamines, acutely elevates blood pressure and has been linked to higher AD risk [61, 62]. National Survey on Drug Use and Health (NSDUH) data indicate that adults aged 35–44 have among the highest prevalence of illicit stimulant use, with past-year central nervous system stimulant use reported at ~ 9.5% for ages 35–39 and ~ 8.8% for ages 40–44, highlighting this age group as a key population for stimulant exposure [63].
Therefore, promoting healthy lifestyles among the general population and lowering the age threshold for targeted aortic disease screening are crucial to reducing the overall AAMR.
Regarding the racial-level changes in AAMR. First, prior to 2017, the NH White population exhibited a significantly higher degree of aging compared with the NH Black population, with the proportion of individuals aged 80 + years in NH White being 1.8 times that in NH Black [64]. As both AA and AD are typical “age-related diseases” with exponentially increasing incidence and mortality risks with age [54], this demographic difference likely contributed to the higher disease burden in NH White than in NH Black during this period. Second, U.S. aortic disease screening programs (e.g., abdominal ultrasound screening) have primarily prioritized NH White-dominant areas with adequate healthcare resources, resulting in a significantly higher AA/AD diagnosis rate in NH White than in NH Black [65]. However, subsequent trends indicate that NH Black populations may not have benefited equally from existing medical advances. On one hand, the overall income level and health insurance coverage rate of NH Black individuals are significantly lower than those of NH White and Hispanic populations. Meanwhile, the outpatient visit rate for aortic aneurysms and ultrasound screening rate among Black individuals are significantly lower than those among White individuals [66]. Third, hypertension and smoking are particularly prevalent among NH Black individuals—both are major risk factors for the development and progression of AA/AD. This increases the risk of AA/AD onset and severity, elevates treatment complexity, and reduces access to surgical intervention, ultimately resulting in a slower decline in AAMR among NH Black than in NH White [67,68,69].
In addition to socioeconomic and healthcare disparities, emerging evidence suggests that biological susceptibility may also contribute to the higher burden of aortic diseases in Black populations. Black individuals have been shown to exhibit greater arterial stiffness, as measured by pulse wave velocity, compared with White individuals, indicating earlier vascular aging and mechanical vulnerability of the aortic wall [70]. Impaired endothelial function, including reduced nitric oxide-mediated vasodilation and increased arterial wave reflections, has been observed in Black adults independent of traditional risk factors, which may further compromise vascular resilience [71]. Moreover, hypertension tends to develop earlier and with greater severity in Black populations, thereby prolonging exposure to elevated aortic wall stress that promotes medial degeneration and dissection risk [72]. Although genetic determinants of extracellular matrix remodeling and smooth muscle cell function may also modulate aortic wall integrity, these mechanisms remain underexplored across racial groups and warrant further investigation.
On the other hand, the slow decline in AAMR among NH Black individuals is also closely associated with the failure of their comorbidity control rate to improve synchronously with advances in medical technology. Therefore, targeted public health interventions and policies are urgently needed to improve access to prevention, diagnosis, and treatment services in underserved communities. This could include expanding affordable healthcare coverage, implementing community health education programs (e.g., hypertension management, smoking cessation), enhancing screening for high-risk ethnic groups, and promoting healthcare team diversity and culturally competent services to eliminate health disparities and achieve equitable health outcomes.
Finally, our study revealed the highest AAMR in the Midwest region geographically, with such disparities potentially driven by risk exposure, healthcare infrastructure and demographic structure. CDC BRFSS data indicate that adult obesity prevalence is highest in the Midwest and South, at approximately 36.0% and 34.7%, respectively, compared with 28.6% in the Northeast and 29.1% in the West [73]. According to 2016 BRFSS data, obesity prevalence in nonmetropolitan counties was 34.2%, significantly higher than the 28.7% observed in metropolitan counties, a pattern consistent across multiple Census regions [74]. Additionally, 2022 NHIS data estimate that approximately 19.8% of U.S. adults are current smokers; although smoking prevalence has declined overall, it remains relatively high in the Midwest and rural areas [75]; Concurrently, some areas within the Midwest exhibit a higher degree of aging, and older populations have reduced vascular elasticity and a higher incidence of atherosclerosis, which further elevates the baseline disease mortality rate [76]. Finally, compared with the Midwest, several states in the Northeast and South exhibit a higher concentration of healthcare resources, greater density of tertiary hospitals, and more developed emergency care networks for aortic diseases, which may contribute to the observed reduction in mortality [77].
Furthermore, AAMR was higher in Nonmetropolitan areas than in Metropolitan areas, reflecting prevalent socioeconomic challenges in Nonmetropolitan regions—such as higher poverty rates and lower educational attainment—which may limit access to healthcare and resources required for effective disease management, further contributing to elevated mortality [8, 78]. Additionally, Metropolitan areas typically have better health insurance coverage and financial capacity to afford advanced treatments, whereas such therapeutic options are less accessible in Nonmetropolitan areas—this discrepancy may exacerbate disparities in disease outcomes [79]. Further efforts to narrow the healthcare disparity between Nonmetropolitan and Metropolitan areas could be achieved by enhancing awareness among healthcare providers and patients, expanding training for surgeons specializing in endovascular techniques, and implementing policies such as subsidies to reduce barriers in underserved regions.
The geographic distribution of these behavioral risk factors aligns with regions of high chronic disease and AA/AD burden, suggesting that lifestyle behaviors and disparities in healthcare resources may partially explain regional differences in mortality.
Limitations
This study is subject to several limitations. First, the CDC WONDER database lacks individual-level risk factor and care variables (smoking history, BP control, screening/medication use, insurance, treatment type, hospital capability), precluding robust causal explanation of mortality trends and disparities. The database also lacks detailed individual socioeconomic status, precluding comprehensive confounding adjustment and accurate assessment of individual-level mortality drivers. Potential survivor bias exists in the 85 + age group, as this population represents a more health-resilient subset of the general population; individuals with severe AA/AD or multiple comorbidities may not survive to this advanced age, potentially underestimating the true AA/AD mortality burden in this group.
Second, despite the application of age adjustment, this study did not fully quantify the relative contributions of advancing diagnostic and therapeutic technologies to the observed mortality trends over the 25-year study period. The widespread clinical adoption of CT/MRI in the later years likely enhanced the identification of AA/AD cases, which may have led to undercounting in the early years (1999–2000 s) and thus created the illusion of a more pronounced mortality decline than the actual reduction in disease burden. Concomitantly, therapeutic advances—including the development and clinical use of TEVAR/EVAR, stent technologies, and multidisciplinary aortic care teams—have directly reduced fatal AA/AD outcomes. Notably, the CDC WONDER database lacks granular data on diagnostic modality utilization, treatment patterns, and hospital technological access, precluding the disentanglement of these artifactual and genuine effects on mortality. Additionally, temporal changes in healthcare utilization patterns throughout the study period were not fully accounted for in our analytical model. Additionally, while consistent ICD-10 coding was used throughout the study, gradual improvements in coding practices and physician awareness of AA/AD over 25 years may have enhanced case detection and documentation in later years, which could slightly attenuate the observed downward mortality trend.
Thirdly, as a population-based mortality database, mortality information is collected by state registries and provided to the National Vital Statistics System. Data are based on death certificates for U.S. residents.But CDC WONDER does not provide individual-level details on the specific diagnosing provider (e.g., name, years of experience) or the exact diagnostic workflow for each case.we cannot verify the individual experience level of each provider or the specific imaging/autopsy protocols used for each case.
Fourthly, a notable inherent limitation of the CDC WONDER database is the temporal inconsistency in urban-rural data: urban-rural mortality data were only available for the period 1999–2020, whereas data for other stratifications (sex, age, race/ethnicity, and region) covered 1999–2023, as the urban-rural classification data for 2021–2023 have not yet been released. This temporal discrepancy has somewhat reduced the comprehensiveness of the analysis on urban-rural disparities in recent years.
Finally, reliance on death certificate data from CDC WONDER is prone to misclassification bias of AA/AD-related deaths. We also cannot distinguish between incident and prevalent AA/AD cases, as the database contains no information on the timing of disease diagnosis, limiting interpretation of mortality trends related to disease onset versus progression. On one hand, while we restricted our analysis to AA/AD as the underlying cause of death to minimize misclassification, residual bias in death certificate coding of primary vs. secondary etiologies may still exist; on the other hand, although cases were identified using the ICD-10 code I71 series, variations in diagnostic coding practices and reporting standards across different regions may have impacted the accuracy of case inclusion and the comparability of mortality data..
