American Indians and atrial fibrillation

The American Indian population is known to experience high rates of cardiovascular disease and have a heightened vulnerability to severe outcomes driven by an overall poor health status and lower access to quality health care. Our group has previously published an analysis demonstrating that American Indians have the highest risk of atrial fibrillation (AF), as well as of AF-related stroke, when compared with other races and ethnicities. Despite this, AF in this population has not been extensively studied and additional publications are scarce. Our review article provides an up-to-date summary of the relevant literature addressing the relationship between race, ethnicity, and AF by focusing on American Indians. The American Indian population is known to experience high rates of cardiovascular disease and have a heightened vulnerability to severe outcomes driven by an overall poor health status and lower access to quality health care. Our group has previously published an analysis demonstrating that American Indians have the highest risk of atrial fibrillation (AF), as well as of AF-related stroke, when compared with other races and ethnicities. Despite this, AF in this population has not been extensively studied and additional publications are scarce. Our review article provides an up-to-date summary of the relevant literature addressing the relationship between race, ethnicity, and AF by focusing on American Indians. Key Findings▪American Indians and Alaska Natives experience high rates of cardiovascular disease.▪They also have the highest risk of atrial fibrillation (AF) and AF-related stroke compared with other racial and ethnic groups.▪We provide an up-to-date summary on the relationship between race, ethnicity, and AF with a focus on American Indians and Alaska Natives. ▪American Indians and Alaska Natives experience high rates of cardiovascular disease.▪They also have the highest risk of atrial fibrillation (AF) and AF-related stroke compared with other racial and ethnic groups.▪We provide an up-to-date summary on the relationship between race, ethnicity, and AF with a focus on American Indians and Alaska Natives. It is important to discuss the risks and consequences of atrial fibrillation (AF) in American Indian and Alaska Native populations by first considering the broader context of overall cardiovascular health. In general, American Indians experience particularly high rates of cardiovascular disease (CVD).1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar,2Howard B.V. Lee E.T. Cowan L.D. et al.Rising tide of cardiovascular disease in American Indians: the Strong Heart Study.Circulation. 1999; 99: 2389-2395Crossref PubMed Scopus (361) Google Scholar American Indians develop CVD at earlier ages than whites, and CVD is the primary cause of death in over one-third of American Indian deaths occurring before the age of 65 years.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar This has translated into a lower life expectancy that is 5.5 years less in American Indians than non–American Indians.3Indian Health Service. Disparities.https://www.ihs.gov/newsroom/factsheets/disparities/Date accessed: May 10, 2022Google Scholar A variety of risk factors have been shown to contribute to this heightened rate of CVD. American Indians have the highest rates of diabetes mellitus, hypertension, chronic kidney disease, smoking, and coronary heart disease in the United States.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar,2Howard B.V. Lee E.T. Cowan L.D. et al.Rising tide of cardiovascular disease in American Indians: the Strong Heart Study.Circulation. 1999; 99: 2389-2395Crossref PubMed Scopus (361) Google Scholar,4Howard B.V. Lee E.T. Yeh J.L. et al.Hypertension in adult American Indians: the Strong Heart Study.Hypertension. 1996; 28: 256-264Crossref PubMed Scopus (85) Google Scholar,5Welty T.K. Lee E.T. Yeh J. et al.Cardiovascular disease risk factors among American Indians: the Strong Heart Study.Am J Epidemiol. 1995; 142: 269-287Crossref PubMed Scopus (257) Google Scholar Diabetes mellitus is the most important risk factor for CVD in this population, and there is a 3-fold higher age-adjusted prevalence of diabetes compared with whites.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar Cigarette smoking, alcohol use, and physical inactivity have also been identified as significant modifiable behaviors strongly linked to overall CVD.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar Unlike other groups, smoking rates have not recently declined in American Indians, with estimates that 32% of American Indians smoke compared with 16% in other groups.6Blue V. Jernigan B. Duran B. Ahn D. Winkleby M. Changing patterns in health behaviors and risk factors related to cardiovascular disease among American Indians and Alaska Natives.Am J Public Health. 2010; 100: 677-683Crossref PubMed Scopus (92) Google Scholar Alcohol use is variable but reported to be as high as 60% and highly dependent on geographical location.7Beals J. Spicer P. Mitchell C.M. et al.Racial disparities in alcohol use: comparison of 2 American Indian Reservation populations with national data.Am J Public Health. 2011; 93: 1683-1685Crossref Scopus (87) Google Scholar Several studies among American Indian and Alaska Native individuals have aimed to investigate the possible genetic role of CVD: it has been observed that heritability patterns of disease exist and contribute to almost 50% of the phenotypes of obesity, dyslipidemia, hypertension, and diabetes mellitus.8North K.E. Howard B.V. Welty T.K. et al.Genetic and environmental contributions to cardiovascular disease risk in American Indians: the Strong Heart Family Study.Am J Epidemiol. 2003; 157: 303-314Crossref PubMed Scopus (161) Google Scholar A separate study observed that a single set of genes may explain differential risk factors of obesity and low-density lipoprotein size in the American Indian and Alaska Native population.9Saroja Voruganti V. Cai G. Cole S.A. et al.Common set of genes regulates low-density lipoprotein size and obesity-related factors in Alaskan Eskimos: results from the GOCADAN study.Am J Hum Biol. 2006; 18: 525-531Crossref PubMed Scopus (16) Google Scholar Social determinants of health and access to quality health care have direct impacts on the overall morbidity and mortality associated with CVD across all populations, phenomena that may be especially pertinent to American Indian individuals. A lower attained level of education has been a reliable predictor of enhanced CVD risk and is related to employment opportunities.10Redmond N. Richman J. Gamboa C.M. et al.Perceived stress is associated with incident coronary heart disease and all-cause mortality in low- but not high-income participants in the Reasons for Geographic And Racial Differences in Stroke study.J Am Heart Assoc. 2013; 2e000447Crossref PubMed Scopus (79) Google Scholar Less than one-quarter of American Indians have an advanced graduate or professional degree, and there are particularly high rates of unemployment.11Race/Ethnicity and American Indian & Alaska Native Documentation.https://www.census.gov/programs-surveys/acs/data/race-aian.htmlDate accessed: May 10, 2022Google Scholar Poverty rates are highest in American Indians compared with other racial and ethnic minority groups, with certain tribes experiencing nearly triple the national rate.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar Finally, American Indians are underinsured, with only 43% having commercial health insurance coverage and 19% having no insurance coverage.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar In an effort to ameliorate care gaps in this population, the Indian Health Services (IHS) was established and provides medical services and community programs in primary outpatient and emergency care. IHS, however, provides care to less than one-third of the American Indian and Alaska Native population and, unfortunately, facilities are small and less available in urban centers.12U.S. GovernmentAccountability Office. Indian Health Service: Spending Levels and Characteristics of IHS and Three Other Federal Health Care Programs.https://www.gao.gov/products/gao-19-74rDate accessed: August 4, 2022Google Scholar Clinics also lack specialty care and are understaffed by primary care providers with vacancy rates as high as 31%.12U.S. GovernmentAccountability Office. Indian Health Service: Spending Levels and Characteristics of IHS and Three Other Federal Health Care Programs.https://www.gao.gov/products/gao-19-74rDate accessed: August 4, 2022Google Scholar This is further exacerbated by low provider salaries when compared with local market rates.12U.S. GovernmentAccountability Office. Indian Health Service: Spending Levels and Characteristics of IHS and Three Other Federal Health Care Programs.https://www.gao.gov/products/gao-19-74rDate accessed: August 4, 2022Google Scholar Finally, there are ongoing concerns with overall funding of IHS especially in comparison with other federal health programs. In 2017, IHS per capita spending was 50% less than Medicaid, 62% less than the Veterans Health Administration, and 70% less than Medicare.12U.S. GovernmentAccountability Office. Indian Health Service: Spending Levels and Characteristics of IHS and Three Other Federal Health Care Programs.https://www.gao.gov/products/gao-19-74rDate accessed: August 4, 2022Google Scholar Addressing and improving this population’s social determinants of health is complex and requires multifaceted community efforts. There are several IHS- and Centers for Disease Control and Prevention–developed community-based programs that have tried to achieve risk reduction of CVD.13Ferdinand K.C. Patterson K.P. Taylor C. Fergus I.V. Nasser S.A. Ferdinand D.P. Community-based approaches to prevention and management of hypertension and cardiovascular disease.J Clin Hypertens (Greenwich). 2012; 14: 336-343Crossref PubMed Scopus (36) Google Scholar,14Special Diabetes Program for Indians. SDPI Toolkit.https://www.ihs.gov/sdpi/sdpi-toolkits/Date accessed: August 8, 2022Google Scholar Success of these programs will likely depend on establishing relationships and trust within the community, empowering and supporting tribes; identifying a multidisciplinary team of care managers, health educators, and clinicians; and monitoring progress with an action plan.1Breathett K. Sims M. Gross M. et al.Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association.Circulation. 2020; 141: E948-E959Crossref PubMed Scopus (47) Google Scholar Despite the fact that American Indians and Alaska Natives generally exhibit substantially increased rates of CVD and established AF risk factors, AF has not been extensively studied in this population. AF is the most commonly encountered cardiac arrhythmia among all Americans and is the second most common cardiovascular condition after hypertension.15January C.T. Wann L.S. Alpert J.S. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society.Circulation. 2014; 130: e199-e267Crossref PubMed Scopus (1290) Google Scholar,16Tsao 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 (643) Google Scholar In the United States, AF affects 4 million individuals each year, and the prevalence is estimated to increase to at least 12 million by 2030.17Go A.S. Hylek E.M. Phillips K.A. et al.Prevalence of diagnosed atrial fibrillation in adults.JAMA. 2001; 285: 2370-2375Crossref PubMed Scopus (5191) Google Scholar,18Colilla S. Crow A. Petkun W. Singer D.E. Simon T. Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population.Am J Cardiol. 2013; 112: 1142-1147Abstract PubMed Scopus Google Scholar The of individuals with AF are over the age of 65 however, to rates of obesity, diabetes mellitus, and hypertension in AF is to individuals at a A.S. Hylek E.M. Phillips K.A. et al.Prevalence of diagnosed atrial fibrillation in adults.JAMA. 2001; 285: 2370-2375Crossref PubMed Scopus (5191) Google S. Crow A. Petkun W. Singer D.E. Simon T. Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population.Am J Cardiol. 2013; 112: 1142-1147Abstract PubMed Scopus Google S. et of age on the of atrial fibrillation J 2014; PubMed Scopus Google Scholar AF is associated with significant morbidity and with AF may experience a of and of to AF results in quality of and G. D. D. and quality of life in patients with atrial PubMed Scopus Google Scholar It is also the most common cause of stroke, the risk for stroke by to 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 (643) Google Scholar have also been associated with AF and in chronic kidney disease, and P. et fibrillation and the risk of 2014; PubMed Scopus Google N. D. 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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 (643) Google Scholar This into an estimated in health care spending with per with AF per in the United of AF 2011; PubMed Scopus Google N. M. of cardiac for atrial fibrillation: for health care and Google Scholar and have been shown to have differential on not only the but also AF is and associated these relationships is in particularly among American Indians and Alaska as racial and ethnic have likely in the lower rate of care in these The first studies on the of and AF that Americans have a lower risk of AF compared with AF risk A.S. Hylek E.M. Phillips K.A. et al.Prevalence of diagnosed atrial fibrillation in adults.JAMA. 2001; 285: 2370-2375Crossref PubMed Scopus (5191) Google A. et of atrial fibrillation in and the in study.Am Heart J. 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