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Objectives Reductions in US cardiovascular (CVD) mortality have stagnated. While other high life expectancy countries (HLC) have also recently experienced a stall, the stagnation in CVD mortality in the US appeared earlier and has been more pronounced. The reasons for the stall are unknown. We analyze cross-national variations in mortality trends to quantify the US exceptionality and provide insight into its underlying causes. Methods Data are from the WHO (2000-2016). We quantified differences in levels and trends of CVD mortality between the US and 17 other HLC. We decomposed differences to identify the individual contributions of major CVD sub-classifications (ischemic heart disease [IHD], stroke, other heart disease). To identify potential behavioral explanations, we compared trends in CVD mortality with trends in other causes of death related to obesity, smoking, alcohol, and drugs. Results Our study has four central findings: (I) US CVD mortality is consistently higher than the average of other HLCs; (II) the US-HLC gap declined until around 2008, and increased thereafter; (III) the shift from convergence to divergence was mainly driven by slowing IHD and stroke mortality reductions, and increasing mortality from other CVD causes; (IV) among the potential risk factors, only obesity- and alcohol-related mortality showed age-specific temporal changes that are similar to those observed for cardiovascular mortality. Discussion The exceptional changes in US CVD mortality are driven by a distinct pattern of slowing reductions in IHD and stroke mortality and deteriorating mortality from other CVD causes. Obesity and alcohol abuse appear to be interrelated factors.

Cardiovascular Mortality Gap Between the United States and Other High Life Expectancy Countries in 2000–2016