Increasing Acute Coronary Syndrome Mortality in Cirrhosis After a Period of Decline: A National Analysis of Temporal and Demographic Disparities.

Background: How acute coronary syndrome (ACS) mortality has evolved among people with cirrhosis at the national level is unclear, and the clinical implications for cardio-hepatic care are underdefined.

Methods: Using CDC WONDER mortality files (1999-2020), we identified deaths with ACS as the underlying cause and cirrhosis listed among multiple causes, computed age-adjusted mortality rates (AAMRs; per 100,000), and modeled trends with Joinpoint regression. Subgroups included sex, race/ethnicity, urbanization, and place of death.

Results: We identified 10,319 cirrhosis-associated ACS deaths; the overall AAMR was 0.22. Rates were higher in men than women (0.33 vs. 0.12) and higher in Hispanic than non-Hispanic individuals (0.31 vs. 0.20). American Indian/Alaska Native had the highest AAMR (0.34). Rural noncore counties had the highest AAMR (0.28). Joinpoint detected a national inflection in 2014: AAMR declined from 1999 to 2014 (APC - 3.49%) and increased thereafter (APC + 5.38%), with an overall AAPC of -1.03%.

Conclusions: After years of decline, cirrhosis-associated ACS mortality has risen since 2014, with persistent disparities by sex, race/ethnicity, and rurality. These data support integrated cardio-hepatic pathways, targeted outreach to rural and historically underserved groups, and system-level quality improvement focused on time-sensitive ACS care in cirrhosis.