Disparities in cardiovascular care: Past, present, and solutions

Cleveland Clinic Journal of Medicine. 2019 September;86(9):621-632 | 10.3949/ccjm.86a.18088
September 3, 2019|Cleveland Clinic Journal of Medicine
Quentin R. Youmans, MD;Lindsey Hastings-Spaine, MD;Oluseyi Princewill, MD, MPH;Titilayo Shobayo;BS;Ike S. Okwuosa, MD
Author and Disclosure Information

Quentin R. Youmans, MD
Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL

Lindsey Hastings-Spaine, MD
Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, NJ

Oluseyi Princewill, MD, MPH
MedStar Health Cardiology Associates, Olney, MD

Titilayo Shobayo, BS
Morehouse School of Medicine, Atlanta, GA

Ike S. Okwuosa, MD
Assistant Professor of Medicine, Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL

Address: Ike S. Okwuosa, MD, Feinberg School of Medicine, Division of Cardiology, Northwestern University, 676 N St. Clair Street, Chicago, IL 60611; isokwuosa@gmail.com

Release date: September 1, 2019
Expiration date: August 31, 2020
Estimated time of completion: 1 hour

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ABSTRACT

Cardiovascular disease has been the leading cause of death in the United States since the early 20th century. With advances in prevention and treatment, cardiovascular mortality rates are on the decline. Nevertheless, disparities in care persist, with devastating impact in select populations in the United States. This paper reviews the impact of disparate care on risk-factor burden, coronary artery disease, heart failure, and cardiovascular research.

KEY POINTS

  • Although avoidable deaths from heart disease, stroke, and hypertensive disease have declined overall, African Americans still have a higher mortality rate than other racial and ethnic groups.
  • The prevalence of modifiable risk factors for cardiovascular disease is higher in African Americans than in the general US population.
  • Disparities in care exist and may persist even with equal access to care.
  • Since 1993, studies funded by the National Institutes of Health must include minorities that were historically underrepresented in clinical research trials.
  • Solutions to disparities will need to eliminate healthcare bias, increase patient access, and increase diversity and inclusion in the physician work force.
  • Cardiovascular disease makes no distinction in race, sex, age, or socioeconomic status, and neither should the medical community.

Nutrition and obesity

Nutrition plays a major role in cardiovascular disease, specifically in the pathogenesis of atherosclerotic disease and hypertension.24 Most Americans do not meet dietary recommendations, with minority communities performing worse in specific metrics.7

Dietary patterns are reflected in the rate of obesity in this nation. Studies have shown a direct correlation between obesity and cardiovascular disease such as coronary artery disease, heart failure, and atrial fibrillation.25–28 According to data from the National Health and Nutrition Examination Survey (NHANES), 31% of children between the ages of 2 and 19 years are classified as obese or overweight. The highest rates of obesity are seen in Hispanic and African American boys and girls. The obesity epidemic is disproportionately rampant in children living in households with low income, low education, and high unemployment rates.7,29–31

Despite the risks associated with obesity, only 64.8% of obese adults report being informed by a doctor or health professional that they were overweight. The proportion of obese adults informed that they were overweight was significantly lower for African Americans and Hispanics compared with whites. Similar differences are seen based on socioeconomic status, as middle-income patients were less likely to be informed than those in the higher income strata (62.4% vs 70.6%).7,31

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Blood pressure

Hypertension is a well-established risk factor for cardiovascular disease and stroke, and a blood pressure of 120/80 mm Hg or lower is identified as a component of ideal cardiovascular health.

In the United States the prevalence of hypertension in adults older than 20 is 32%.7 The prevalence of hypertension in African Americans is among the highest in the world.32,33 African Americans develop high blood pressure at earlier ages, and their average resting blood pressures are higher than in whites.34,35 For a 45-year-old without hypertension, the 40-year risk of developing hypertension is 92.7% for African Americans and 86% for whites.35 Hypertension is a major risk factor for stroke, and African Americans have a 1.8 times greater rate of fatal stroke than whites.7

In 2013 there were 71,942 deaths attributable to high blood pressure, and the 2011 death rate associated with hypertension was 18.9 per 100,000. By race, the death rate was 17.6 per 100,000 for white males and an alarming 47.1 per 100,000 for African American males; rates were 15.2 per 100,000 for white females and 35.1 per 100,000 for African American females.7

It is unclear what accounts for the racial difference in prevalence in hypertension. Studies have shown that African Americans are more likely than whites to have been told on more than 2 occasions that they have hypertension. And 85.7% of African Americans are aware that they have high blood pressure, compared with 82.7% of whites.14

African Americans and Hispanics have poorer hypertension control compared with whites.36,37 These observed differences cannot be attributed to access alone, as African Americans were more likely to be on higher-intensity blood pressure therapy, whereas Hispanics were more likely to be undertreated.36,38 In a meta-analysis of 13 trials, Peck et al39 showed that African Americans showed a lesser reduction in systolic and diastolic blood pressure when treated with angiotensin-converting enzyme (ACE) inhibitors.

The 2017 American College of Cardiology (ACC) and AHA guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults40 identifies 4 drug classes as reducing cardiovascular disease morbidity and mortality: thiazide diuretics, ACE inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers. Of these 4 classes, thiazide diuretics and calcium channel blockers have been shown to lower blood pressure more effectively in African Americans than renin-angiotensin-aldosterone inhibition with ACE inhibitors or ARBs.

Glycemic control

Type 2 diabetes mellitus secondary to insulin resistance disproportionately affects minority groups, as the prevalence of diabetes mellitus in African Americans is almost twice as high as that in whites, and 35% higher in Hispanics compared with whites.7,41 Based on NHANES data between 1984 and 2004, the prevalence of diabetes mellitus is expected to increase by 99% in whites, 107% in African Americans, and 127% in Hispanics by 2050. Alarmingly, African Americans over age 75 are expected to experience a 606% increase by 2050.42

With regard to mortality, 21.7 deaths per 100,000 population were attributable to diabetes mellitus according to reports by the AHA in 2016. The death rate in white males was 24.3 per 100,000 compared with 44.9 per 100,000 for African Americans males. The associated mortality rate for white women was 16.2 per 100,000, and 35.8 per 100,000 for African American females.7