Background: Hemorrhagic stroke with coagulopathies carries a high risk of mortality and disability. Despite advances in care, disparities by race, region, and sex remain underexamined. This study analyzes national mortality trends (1999–2020) to uncover inequities and evolving patterns in stroke-related outcomes.

Methods: Mortality data from CDC WONDER (1999–2020) were analyzed using ICD-10 codes I60–I62 for hemorrhagic stroke and D65–D69 for coagulopathies. Age-adjusted mortality rates per 100,000 were calculated using the 2000 U.S. standard population. Joinpoint regression estimated annual and average annual percent change (APC/AAPC) with 95% CIs across age, sex, race/ethnicity, region, and urbanization.

Results Between 1999 and 2020, a total of 32,696 hemorrhagic stroke deaths with underlying coagulopathies were recorded in the United States. The age-adjusted mortality rate (AAMR) slightly declined from 0.675 in 1999 to 0.659 in 2020. In 1999, the highest AAMR was observed in females (0.806) and the lowest in males (0.577); by 2020, females continued to have the highest AAMR (0.845), while males had the lowest (0.528). Regionally, the West had the highest AAMR in both 1999 (0.841) and 2020 (0.819), whereas the Midwest had the lowest in 1999 (0.571) and in 2020 (0.59). Among racial/ethnic groups, Black individuals had the highest AAMR in 1999 (0.790), while Hispanics had the lowest (0.600); in 2020, White individuals had the highest AAMR (0.774), and Black individuals the lowest (0.671). Rural areas had lower AAMRs than urban areas in both years, with the lowest in 1999 (0.619) and 2020 (0.654).

Trend analysis showed the greatest AAMR decline among Black individuals (AAPC: –1.85%; 95% CI: –2.37 to –1.32;), while the smallest significant decline was among NH Asian or Pacific Islander (AAPC: –1.49%; 95% CI: –2.53 to -0.44;). Regionally, the South experienced the greatest improvement (AAPC: –0.97%; 95% CI: –1.76 to –0.17; ), while the Northeast had the smallest significant change (AAPC: –0.67%; 95% CI: –1.2 to -0.14;). Females experienced a greater non significant decline than males (AAPC: –0.60%; 95% CI: –2.43 to 1.26 vs. –0.27%; 95% CI: –0.66 to 0.12; ). Urban areas showed a greater, though not statistically significant, decline (AAPC: –0.50%; 95% CI: –1.16 to 0.16) compared to rural areas (AAPC: –0.07%; 95% CI: –0.67 to 0.54; NS).

Crude mortality rates by age showed that in 1999, the 75–84 age group had the highest rate (2.716) and the 25–34 group the lowest (0.107); in 2020, the 85+ group had the highest (2.914) and 25–34 the lowest (0.100). The 65–74 age group had the most significant decline (AAPC: –1.20%; 95% CI: –2.11 to –0.28; ), while the rest were non statistically significant.

Conclusion: Despite a modest national decline, race-based and regional disparities in hemorrhagic stroke mortality with coagulopathies remain pronounced. The steep decline among Black individuals contrasts with rising rates in Whites, pointing to shifting structural risks and care gaps. Equity-focused strategies must address these evolving patterns.

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2025
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