The Complexity of Racial and Ethnic Disparities in Cardiovascular Health: A Role for Underrepresented Populations-Focused Clinics?

Racial and ethnic disparities in cardiovascular (CV) health care and outcomes continue to affect non-White communities, especially Black women. In this editorial, “Black” will be used to include persons identified as African Americans, non-Hispanic Black, or of African Ancestry, and “White” will include persons of European ancestry.1Flanagin A. Frey T. Christiansen S.L. Updated guidance on the reporting of race and ethnicity in medical and science journals.JAMA. 2021; 326: 621-627Crossref PubMed Scopus (466) Google Scholar In the United States, the prevalence of coronary heart disease (CHD) is higher in Black women, and its decline has been less pronounced compared with that of White women.2Rosamond W.D. Chambless L.E. Heiss G. et al.Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987-2008.Circulation. 2012; 125: 1848-1857Crossref PubMed Scopus (271) Google Scholar,3Tsao C.W. Aday A.W. Almarzooq Z.I. et al.Heart disease and stroke statistics–2022 update: a report from the American Heart Association.Circulation. 2022; 145: e153-e639Crossref PubMed Scopus (1801) Google Scholar Black women are generally younger at the time of myocardial infarction, are at higher risk of hospitalization and angina postrevascularization, and present the highest risk of CV death in the United States.4Blackston J.W. Safford M.M. Mefford M.T. et al.Cardiovascular disease events and mortality after myocardial infarction among black and white adults: REGARDS study.Circ Cardiovasc Qual Outcomes. 2020; 13e006683Crossref PubMed Scopus (15) Google Scholar, 5Hess C.N. Kaltenbach L.A. Doll J.A. Cohen D.J. Peterson E.D. Wang T.Y. Race and sex differences in post-myocardial infarction angina frequency and risk of 1-year unplanned rehospitalization.Circulation. 2017; 135: 532-543Crossref PubMed Scopus (31) Google Scholar, 6Kyalwazi A.N. Loccoh E.C. Brewer L.C. et al.Disparities in cardiovascular mortality between black and white adults in the United States, 1999 to 2019.Circulation. 2022; 146: 211-228Crossref PubMed Scopus (21) Google Scholar Factors contributing to these CV disparities include higher prevalence and magnitude of effect of traditional and female-specific CV risk factors (ie, hypertensive disorders of pregnancy, gestational diabetes) among Black women, which are driven most prominently by social and lifestyle determinants of health (SDOH), as well as the presence of genetic and biological differences involved in the pathophysiology of CV disease.7Mehta L.S. Velarde G.P. Lewey J. et al.Cardiovascular disease risk factors in women: the impact of race and ethnicity: a scientific statement from the American Heart Association.Circulation. 2023; 147: 1471-1487Crossref PubMed Scopus (4) Google Scholar Adverse SDOH largely contribute to the worse CV health observed among Black women, notably via their impact on lifestyle habits.3Tsao C.W. Aday A.W. Almarzooq Z.I. et al.Heart disease and stroke statistics–2022 update: a report from the American Heart Association.Circulation. 2022; 145: e153-e639Crossref PubMed Scopus (1801) Google Scholar,8Carnethon M.R. Pu J. Howard G. et al.Cardiovascular health in African Americans: a scientific statement from the American Heart Association.Circulation. 2017; 136: e393-e423Crossref PubMed Scopus (640) Google Scholar Examples include lower adherence to recommended diets and reduced physical activity time compared with White people.3Tsao C.W. Aday A.W. Almarzooq Z.I. et al.Heart disease and stroke statistics–2022 update: a report from the American Heart Association.Circulation. 2022; 145: e153-e639Crossref PubMed Scopus (1801) Google Scholar These are generally the result of broader and interconnected SDOH-related factors that encompass social and economic inequities, physical environment, and education among other factors, all contributing to poorer CV health and reduced adherence to preventive and therapeutic CV strategies.9Ogunniyi M.O. Mahmoud Z. Commodore-Mensah Y. et al.Eliminating disparities in cardiovascular disease for Black Women: JACC Review Topic of the Week.J Am Coll Cardiol. 2022; 80: 1762-1771Crossref Scopus (2) Google Scholar Moreover, Black women are more frequently subject to chronic stressors, racial and sexual discrimination, and exposure to violence: elements known to affect CV health but also potentially affecting their trust in the health care system.7Mehta L.S. Velarde G.P. Lewey J. et al.Cardiovascular disease risk factors in women: the impact of race and ethnicity: a scientific statement from the American Heart Association.Circulation. 2023; 147: 1471-1487Crossref PubMed Scopus (4) Google Scholar,9Ogunniyi M.O. Mahmoud Z. Commodore-Mensah Y. et al.Eliminating disparities in cardiovascular disease for Black Women: JACC Review Topic of the Week.J Am Coll Cardiol. 2022; 80: 1762-1771Crossref Scopus (2) Google Scholar Recent evidence suggests that addressing the SDOH could reduce Black vs White disparities in CV risk factors by as much as 50%.10He J. Zhu Z. Bundy J.D. Dorans K.S. Chen J. Hamm L.L. Trends in cardiovascular risk factors in US adults by race and ethnicity and socioeconomic status, 1999-2018.JAMA. 2021; 326: 1286-1298Crossref PubMed Scopus (59) Google Scholar Thus, emerging interventions that address SDOH in addition to traditional prevention of CV disease are critical to CV equity. In this edition of the Canadian Journal of Cardiology, Luu et al.11Luu J.M. Cook-Wiens G. Pepine C.G. et al.Long-term adverse outcomes in black women with obstructive coronary artery disease: a study of the Women’s Ischemia Syndrome Evaluation (WISE) Cohort.Can J Cardiol. 2023; (xxx:xxx-xx)Google Scholar compared the incidence of major adverse cardiovascular events (MACE) between non-Hispanic Black and non-Black participants with obstructive coronary artery disease (CAD)—stenosis ≥ 50%—from the Women’s Ischemia Syndrome Evaluation (WISE) study. The WISE Study was a prospective multicentric observational study, conducted in the United States between 1996 and 2000, that enrolled 944 women with symptoms or signs of cardiac ischemia without acute coronary syndrome and with a clinical indication for coronary angiography.12Merz C.N. Kelsey S.F. Pepine C.J. et al.The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report.J Am Coll Cardiol. 1999; 33: 1453-1461Crossref PubMed Scopus (286) Google Scholar Of these, 364 women had obstructive CAD, among whom 69 (19%) constituted the study group of Black women. The authors showed comparable unadjusted and adjusted risks of MACE between Black and non-Black women after a follow-up of 11.2 years. It is important to acknowledge the authors for their effort in providing race-specific data from the WISE Study, thereby contributing to reducing the gap in CV disparities.13Prasanna A. Miller H.N. Wu Y. et al.Recruitment of Black adults into cardiovascular disease trials.J Am Heart Assoc. 2021; 10e021108Crossref PubMed Scopus (28) Google Scholar Consistent with other published cohorts, Black women in this study by Luu et al. had a less favourable CV risk factor profile and were more frequently affected by adverse SDOH than non-Black women.8Carnethon M.R. Pu J. Howard G. et al.Cardiovascular health in African Americans: a scientific statement from the American Heart Association.Circulation. 2017; 136: e393-e423Crossref PubMed Scopus (640) Google Scholar,9Ogunniyi M.O. Mahmoud Z. Commodore-Mensah Y. et al.Eliminating disparities in cardiovascular disease for Black Women: JACC Review Topic of the Week.J Am Coll Cardiol. 2022; 80: 1762-1771Crossref Scopus (2) Google Scholar,11Luu J.M. Cook-Wiens G. Pepine C.G. et al.Long-term adverse outcomes in black women with obstructive coronary artery disease: a study of the Women’s Ischemia Syndrome Evaluation (WISE) Cohort.Can J Cardiol. 2023; (xxx:xxx-xx)Google Scholar The small sample size, and the fact that other relevant CV risk factors previously associated with adverse CV events were not included, represent significant limitations of this study. For instance, lipid and glucose profiles, previous adverse pregnancy outcomes, and lifestyle habits were not addressed in this secondary analysis.9Ogunniyi M.O. Mahmoud Z. Commodore-Mensah Y. et al.Eliminating disparities in cardiovascular disease for Black Women: JACC Review Topic of the Week.J Am Coll Cardiol. 2022; 80: 1762-1771Crossref Scopus (2) Google Scholar,14Kenkre T.S. Malhotra P. Johnson B.D. et al.Ten-year mortality in the WISE study (Women's Ischemia Syndrome Evaluation).Circ Cardiovasc Qual Outcomes. 2017; 10Crossref PubMed Scopus (71) Google Scholar Information regarding severity of CAD was also not provided.14Kenkre T.S. Malhotra P. Johnson B.D. et al.Ten-year mortality in the WISE study (Women's Ischemia Syndrome Evaluation).Circ Cardiovasc Qual Outcomes. 2017; 10Crossref PubMed Scopus (71) Google Scholar These elements could have influenced the incidence of MACE outcomes differentially between Black and non-Black women. Race-specific outcomes in the context of stable angina are scarce and remain contradictory. The results presented by Luu et al. are contrasting with those previously published in a 3-year follow-up study of patients with stable angina, in which Black subjects had a 30% higher risk of MACE at 3 years compared with White subjects.11Luu J.M. Cook-Wiens G. Pepine C.G. et al.Long-term adverse outcomes in black women with obstructive coronary artery disease: a study of the Women’s Ischemia Syndrome Evaluation (WISE) Cohort.Can J Cardiol. 2023; (xxx:xxx-xx)Google Scholar,15Povsic T.J. Broderick S. Anstrom K.J. et al.Predictors of long-term clinical endpoints in patients with refractory angina.J Am Heart Assoc. 2015; 4Crossref Scopus (66) Google Scholar Furthermore, more frequent angina and a higher risk of heart failure hospitalization have been reported among Black persons in 2 large prospective cohorts in the United States.16Blumenthal D.M. Howard S.E. Searl Como J. et al.Prevalence of angina among primary care patients with coronary artery disease.JAMA Netw Open. 2021; 4e2112800Crossref Scopus (6) Google Scholar,17Bibbins-Domingo K. Pletcher M.J. Lin F. et al.Racial differences in incident heart failure among young adults.N Engl J Med. 2009; 360: 1179-1190Crossref PubMed Scopus (444) Google Scholar By opposition, a study by Mehran et al. showed no significant differences in the incidence of MACE between Black and non-Black women at 1 year postangioplasty, for stable angina and acute coronary syndrome.18Mehran R. Chandrasekhar J. Davis S. et al.Impact of race and ethnicity on the clinical and angiographic characteristics, social determinants of health, and 1-year outcomes after everolimus-eluting coronary stent procedures in women.Circ Cardiovasc Interv. 2019; 12e006918Crossref Scopus (9) Google Scholar In another secondary analysis of the WISE cohort, the incidence of MACE was compared between 87 Black women (45 [52%] events) and 493 non-Black women (152 [33%] events) without obstructive CAD, showing a significantly higher adjusted hazard ratio (aHR) of MACE in Black women (aHR, 1.57; 95% confidence interval [CI], 1.04-2.38]).19Luu J.M. Malhotra P. Cook-Wiens G. et al.Long-term adverse outcomes in black women with ischemia and no obstructive coronary artery disease: a study of the WISE (Women's Ischemia Syndrome Evaluation) cohort.Circulation. 2023; 147: 617-619Crossref Scopus (1) Google Scholar Despite similar sample sizes, it is noteworthy that this higher risk of MACE was not reproduced among women with obstructive CAD from the same cohort.11Luu J.M. Cook-Wiens G. Pepine C.G. et al.Long-term adverse outcomes in black women with obstructive coronary artery disease: a study of the Women’s Ischemia Syndrome Evaluation (WISE) Cohort.Can J Cardiol. 2023; (xxx:xxx-xx)Google Scholar It remains unclear if these distinctive results are related to factors affecting Black women differently in the context of nonobstructive vs obstructive CAD. Missing relevant confounding factors or a lack of statistical power cannot be fully excluded. This study by Luu et al.11Luu J.M. Cook-Wiens G. Pepine C.G. et al.Long-term adverse outcomes in black women with obstructive coronary artery disease: a study of the Women’s Ischemia Syndrome Evaluation (WISE) Cohort.Can J Cardiol. 2023; (xxx:xxx-xx)Google Scholar is of great interest, as the author raises an important and still unanswered question pertaining to the impact of quality of care on CV outcomes among Black women: Do academic centres provide more inclusive cardiovascular care than community centres? Studies have suggested that Black individuals tend to receive primary care by physicians who are less likely to be board certified and tend to be referred to hospitals with higher rates of mortality.20Bach P.B. Pham H.H. Schrag D. Tate R.C. Hargraves J.L. Primary care physicians who treat blacks and whites.N Engl J Med. 2004; 351: 575-584Crossref PubMed Scopus (798) Google Scholar,21Rangrass G. Ghaferi A.A. Dimick J.B. Explaining racial disparities in outcomes after cardiac surgery: the role of hospital quality.JAMA Surg. 2014; 149: 223-227Crossref PubMed Scopus (168) Google Scholar Further, Black women living in rural areas experience greater CV mortality than their counterparts living in urban areas.6Kyalwazi A.N. Loccoh E.C. Brewer L.C. et al.Disparities in cardiovascular mortality between black and white adults in the United States, 1999 to 2019.Circulation. 2022; 146: 211-228Crossref PubMed Scopus (21) Google Scholar Yet, to our knowledge, no study has formally evaluated the impact of being treated in an academic vs community health care centre on CV outcomes in Black individuals, particularly in the outpatient setting. It is also important to note that the ability to participate in research studies and to access academic centres can involuntarily lead to selection biases, gathering individuals with more favourable SDOH, potentially promoting the selection of patients at lower risk for MACE. The development of institutions dedicated to underserved and underrepresented populations, such as Black women, is a potential avenue for addressing barriers to accessibility and reducing gaps in CV health. Institutions centred on the CV health of women have been developed to address their SDOH and health care disparities,22Parvand M. Cai L. Ghadiri S. et al.One-year prospective follow-up of women with INOCA and MINOCA at a Canadian Women's Heart Centre.Can J Cardiol. 2022; 38: 1600-1610Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,23Pacheco C. Luu J. Mehta P.K. Wei J. Gulati M. Bairey Merz C.N. INOCA and MINOCA: are women's heart centres the answer to understanding and management of these increasing populations of women (and men)?.Can J Cardiol. 2022; 38: 1611-1614Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and this populational approach to CV care may help meet the needs of other underrepresented and undertreated communities, including Black women (Fig. 1). The involvement of communities along with enhanced representation and diversity in the organization and evaluation of services may further reduce barriers to care.7Mehta L.S. Velarde G.P. Lewey J. et al.Cardiovascular disease risk factors in women: the impact of race and ethnicity: a scientific statement from the American Heart Association.Circulation. 2023; 147: 1471-1487Crossref PubMed Scopus (4) Google Scholar,9Ogunniyi M.O. Mahmoud Z. Commodore-Mensah Y. et al.Eliminating disparities in cardiovascular disease for Black Women: JACC Review Topic of the Week.J Am Coll Cardiol. 2022; 80: 1762-1771Crossref Scopus (2) Google Scholar The findings from Luu et al.11Luu J.M. Cook-Wiens G. Pepine C.G. et al.Long-term adverse outcomes in black women with obstructive coronary artery disease: a study of the Women’s Ischemia Syndrome Evaluation (WISE) Cohort.Can J Cardiol. 2023; (xxx:xxx-xx)Google Scholar should be interpreted carefully, in view of the small sample size and subgroup analysis. However, the author raise interesting hypotheses regarding the potential role of institutional factors in improving CV outcomes among Black women. More scientific and clinical programs dedicated to Black women are needed to better identify, understand, and reduce the gaps that they continue to experience in CV health.