Trends and Disparities in Mortality due to Pulmonary Embolism Among Adults With Atrial Fibrillation From 1999 to 2020: Insights From the <scp>CDC</scp> <scp>WONDER</scp> Database

Abstract

Background: Pulmonary embolism (PE) remains a major cause of cardiovascular mortality, and atrial fibrillation (AF) significantly worsens its outcomes. However, long-term trends and disparities in PE mortality among patients with AF remain poorly characterized. Methods: Using the CDC WONDER database (1999-2020), we identified adults with PE as the underlying cause of death and AF as a contributing cause using ICD-10 codes I26 and I48. Age-adjusted mortality rates (AAMRs) and annual percentage changes (APCs) were calculated via Joinpoint regression. Subgroup analyses were done based on the pre-, during, and post-COVID-19 pandemic era. Results: A total of 5499 deaths were recorded with PE and coexisting AF. Overall mortality remained stable from 1999 to 2009 (APC: -0.27; 95% CI: -2.12 to 1.60), then rose sharply from 2009 to 2020 (APC: 3.68; 95% CI: 2.29-5.10). Males had higher mortality (AAMR: 0.077) than females (0.065), with faster increases over time. Non-metropolitan areas showed greater mortality (AAMR: 0.082) than metropolitan areas (0.063), with steeper APCs (2.73% vs. 2.00%). Regionally, the Midwest (AAMR: 0.077) and South (0.073) bore the highest burden. States with the highest mortality included Vermont and Maryland. Most deaths occurred in inpatient settings (55.7%), followed by nursing homes (15.8%) and decedents' homes (14.5%). Notably, states with the lowest AAMRs were New York, Louisiana, and Florida. Conclusions: Mortality due to PE with AF as a contributor has increased significantly since 2009, with marked sex, regional, and urban-rural disparities. These findings underscore the growing public health burden and the need for targeted regional responses.