BACKGROUND: Native Hawaiian and Pacific Islander (NHPI) adults have historically been grouped with Asian adults in U.S. mortality surveillance. Starting in 2018, the 1997 race and ethnicity standards from the U.S. Office of Management and Budget were adopted by all states on death certificates, enabling national-level estimates of cardiovascular disease (CVD) mortality for NHPI adults independent of Asian adults. OBJECTIVE: To describe CVD mortality among NHPI adults. DESIGN: Race-stratified age-standardized mortality rates (ASMRs) and rate ratios were calculated using final mortality data from the National Vital Statistics System for 2018 to 2022. SETTING: Fifty states and the District of Columbia. PARTICIPANTS: Adults aged 35 years or older at the time of death. MEASUREMENTS: CVD deaths were identified from International Classification of Diseases, 10th Revision codes indicating CVD (I00 to I99) as the underlying cause of death. RESULTS: From 2018 to 2022, 10 870 CVD deaths (72.6% from heart disease; 19.0% from cerebrovascular disease) occurred among NHPI adults. The CVD ASMR for NHPI adults (369.6 deaths per 100 000 persons [95% CI, 362.4 to 376.7]) was 1.5 times higher than for Asian adults (243.9 deaths per 100 000 persons [CI, 242.6 to 245.2]). The CVD ASMR for NHPI adults was the third highest in the country, after Black adults (558.8 deaths per 100 000 persons [CI, 557.4 to 560.3]) and White adults (423.6 deaths per 100 000 persons [CI, 423.2 to 424.1]). LIMITATION: Potential misclassification of underlying cause of death or race group. CONCLUSION: NHPI adults have a high rate of CVD mortality, which was previously masked by aggregation of the NHPI population with the Asian population. The results of this study support the need for continued disaggregation of the NHPI population in public health research and surveillance to identify opportunities for intervention. PRIMARY FUNDING SOURCE: National Institute of General Medical Sciences, National Institutes of Health.