Racial/ethnic health disparities in cardiovascular disease during the COVID-19 pandemic: revisiting a long-lasting problem

Race and its intersection with health have become an increasingly visible issue in the last few years. The death of George Floyd and the momentum of the Black Lives Matter movement have brought the issue of race in our society to the forefront, and the global COVID-19 pandemic has again highlighted disparities. The stark racial health disparities were painfully evident as Blacks and Hispanics were disproportionately affected and accounted for a majority of the deaths among American Heart Association’s (AHA’s) COVID-19 Cardiovascular Disease registry.1 And although racial/ethnic health disparities are not new, they have persisted with no clear end in sight. Globally, cardiovascular disease remains the leading cause of death and the World Health Organization (WHO) estimates that about a third of deaths in 2019 were attributable to cardiovascular disease. Mortality from cardiovascular disease remained the leading cause of death in 2020 in the USA even while the COVID-19 pandemic took the world by storm. The reasons for the racial disparities in health are myriad. Historically, racial and ethnic minorities have been disproportionately burdened with traditional risk factors that lead to cardiovascular disease. Compared to non-Hispanic Whites, Blacks and Hispanics have a higher prevalence of hypertension, hyperlipidaemia, diabetes, and obesity in the USA.2 And although strategies have been implemented to improve cardiovascular health, racial/ethnic minorities have had a slower trend towards improvement in these risk factors compared to non-Hispanic Whites. However, the increased prevalence of these risk factors does not entirely explain the differences in cardiovascular mortality between racial/ethnic minorities and non-Hispanic Whites. For example, despite adjusting for the higher prevalence of baseline comorbidities, being Black was an independent predictor of mortality and myocardial infarction following percutaneous coronary intervention.3 Despite having a higher prevalence of heart failure and mortality associated with it, racial/ethnic minorities are also less likely to receive advanced therapies such as cardiac resynchronization therapy with defibrillator or ventricular assist device.4 Addressing the root causes of these disparities is not as simple as blaming differences in ancestry or genetics. Race is a social construct that has become more and more heterogeneous over the years as evidenced by a recent examination of the SPRINT trial. Black participants in the SPRINT trial had no difference in blood pressure across groups with differing proportions of Western African Ancestry, suggesting that external factors, rather than race, ethnicity, or ancestry are at play.5 It is these external factors that need to be focused on if we are to make any significant headway in addressing racial/ethnic disparities. One of the most critical factors is the influence that systemic racism has on racial/ethnic minorities. Systemic racism has disproportionately burdened minorities with worse socioeconomic status, access to healthcare, and food insecurity. Residential segregation and mortgage redlining have also concentrated poverty, environmental pollution, and unsafe living conditions within these populations. Additionally, the cumulative stress and burden of discrimination have been shown to increase systolic blood pressure by up to 10 mmHg in the CARDIA study.6 Many of these factors have been linked to increased cardiovascular disease and mortality. In order to combat the systemic racism that exists within our society, policies need to be implemented in order to improve equity among all populations. For example, we need policies aimed at improving housing, education, employment opportunities, and access to equitable healthcare in order to avoid downstream adverse health outcomes via dismantling systemic racism from the top down. Additionally, implicit bias and treatment disparities due to providers’ pre-existing notions about race have unfortunately played a role in racial health disparities. The landmark Schulman paper has shown that race and sex independently influenced physician clinical decision-making.7 This includes perceived adherence, trustworthiness regarding clinical history, and assessment of social support, family dynamics, and financial situations, among others. This may explain why racial/ethnic minorities are less likely to receive advanced therapies for heart failure as mentioned above and may explain why black patients in the ARIC Community Surveillance Study were found to be less likely to receive guideline-based non-ST-elevation myocardial infarction therapies.4,8 The reckoning that the entire medical community has to face is the implicit bias that all providers have, and to be honest and critical about the way in which this influences treatment decisions. We need to continue to incorporate intervention at all levels of training and practice that challenge our biases. Given the growing diversity of our population, representation of racial/ethnic populations needs to improve in future trials. The lack of diversity in trials thus far makes it impossible to generalize findings to racial/ethnic populations, as recently evidenced by the higher prevalence of atrial fibrillation present in Asians than was previously thought.9 Even when minorities have been included, many studies have aggregated Asians and Hispanics into one group. This becomes problematic given the diversity that exists within these two groups. As evidenced by the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), cardiovascular health scores differ among different Hispanic subgroups, with certain groups more heavily affected by risk factors than others.10 By disaggregating these groups, specific strategies for improving cardiovascular health can be better tailored for the population that is being targeted. There are multiple contributing factors that interact with one another to explain the racial disparities that exist, of which genomics, sociocultural, environmental factors, and provider bias are all included. Though many studies have been done to try to isolate actions that can be done at the individual provider level to address racial disparities, the most impactful and important work must be done at a larger scale. This includes enrolling more minorities in clinical trials, addressing clinician implicit bias, improving minority representation in medicine, and addressing larger social issues that affect equitable delivery of health care. The COVID-19 pandemic has provided a painful reminder of the persistent racial/ethnic disparities that exist and can no longer be ignored. No new data were generated or analysed in support of this research. None. Conflict of interest: none declared. Biography: Celso L. Diaz, MD, is currently a Cardiology Fellow at the University of California, Los Angeles. He completed his MD at the University of California, San Francisco and his Internal Medicine training at Northwestern University. His research interests include racial disparities in cardiovascular health. Biography: Karol E. Watson, MD, PhD, is Professor of Medicine/Cardiology and the John C. Mazziotta Term Chair in Medicine at the Geffen School of Medicine at UCLA. She was honoured to be named Cardiologist of the Year, by the California chapter of the American College of Cardiology (ACC) for 2017–2018. Dr Watson is director of the UCLA Barbra Streisand Women’s Heart Health Program, co-director of the UCLA Program in Preventative Cardiology, and director of the UCLA Cardiology Fellowship. She is a Principal Investigator for several large NIH studies focusing on prevention of heart disease, vascular calcification, hypertension, hypercholesterolaemia, and disparities.