Letter by Noeman et al Regarding Article “Prevalence of American Heart Association Heart Failure Stages in African-American and White Young and Middle-Aged Adults: The CARDIA Study”

HomeCirculation: Heart FailureVol. 13, No. 1Letter by Noeman et al Regarding Article "Prevalence of American Heart Association Heart Failure Stages in African-American and White Young and Middle-Aged Adults: The CARDIA Study" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Noeman et al Regarding Article "Prevalence of American Heart Association Heart Failure Stages in African-American and White Young and Middle-Aged Adults: The CARDIA Study" Maryam Noeman, MBBS Y5, iBSc, Mahmood Ahmad and Yasser Noeman, PhD, MD Maryam NoemanMaryam Noeman University College London (M.N.). , Mahmood AhmadMahmood Ahmad Royal Free Hospital, London (M.A.). and Yasser NoemanYasser Noeman Southend Hospital, Southend-on-Sea, United Kingdom (Y.N.). Originally published21 Jan 2020https://doi.org/10.1161/CIRCHEARTFAILURE.119.006642Circulation: Heart Failure. 2020;13:e006642We read with interest the study by Gidding et al,1 which highlights the link between early risk (stages A/B) and later development of symptomatic heart failure (HF). It was especially notable to see the number of black patients affected. Multiple factors may be contributing to this racial difference, such as socioeconomic background. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial2 compares patients in quintile 1 (Q1; lowest socioeconomic group and with a greater prevalence of black patients) to quintile 5 (Q5). Patients in Q1 were less likely to achieve blood pressure control (odds ratio, 0.48 [95% CI, 0.37–0.63]). Patients in Q1 had higher all-cause mortality (HR, 1.25 [95% CI, 1.10–1.41]), HF hospitalization mortality (HR, 1.26 [95% CI, 1.03–1.55]), and end-stage renal disease (HR, 1.86 [95% CI, 1.26–2.73]). Possible reasons for this include decreased opportunities for a healthy lifestyle, decreased access to care, and environmental factors leading to stress (eg, unemployment).Black patients have key etiological differences in heart failure development and risk: these patients tend to have nonischemic heart failure, with hypertension being the main risk factor. Current trials do not reflect this: in the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure trial (EMPHASIS-HF trial), for example, only 2.5% patients were black, while Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) had 5.1% black patients. This underrepresentation means medications may be provided which do not reflect patient needs and are therefore suboptimal: for example, mineralocorticoid receptor antagonists such as spironolactone are associated with 30% reduction in risk for all-cause mortality (HR, 0.7 [95% CI, 0.59–0.82]) and 36% decrease in risk for cardiac-associated deaths and hospitalization (HR, 0.64 [95% CI, 0.55–0.74]) in non-black patients. However, when examining the black patients, we find that there is no clinically significant effect on all-cause mortality (0.87 [95% CI, 0.47–1.59]) or cardiac-associated deaths and hospitalization (1.18 [95% CI, 0.72–1.94]). In comparison the A-HeFT trial, focusing mainly on black patients, finds 43% improvement in survival (P=0.01) and 33% decrease in rate of hospitalization (P=0.01) in patients using hydralazine/isosorbide dinitrate compared with placebo.3Our current markers for HF may not be reflective of black patient health. NT-proBNP, a strong predictor for HF, has been shown to have decreased efficacy in black patients.4 While NT-proBNP is strongly associated with heart failure in white patients (HR, 1.73 [95% CI, 1.55–1.94]) across all body mass index and estimated glomerular filtration rates, it is attenuated in black patients (HR, 1.51 [95% CI, 1.34–1.70]).Tailored interventions may promote improved blood pressure control and therefore improved HF outcomes. The BARBER-1 trial5 where community barbers provided blood pressure checks to patients led to improved hypertension control rates (8.8% absolute group difference; P=0.036), with systolic blood pressure reduction of −2.5 mmHg (P=0.08). While this barber-based intervention is effective, further interventions need to be carried out on a larger scale.Overall, black patients experience a 50% higher incidence of HF compared with the general population, as well as in increased risk of mortality secondary to HF as compared with white patients.3 Though community interventions are a key part of improving access to health care in these patients, clinicians must endeavor to ensure optimal treatment and diagnosis, with further research into key markers and medications in these subgroups.DisclosuresNone.References1. Gidding S, Lloyd-Jones D, Lima J, Ambale-Venkatesh B, Shah S, Shah R, Lewis C, Jacobs D, Allen N. Prevalence of American Heart Association Heart Failure Stages in Black and White Young and Middle-Aged Adults.CircHeart Fail. 2019; 12:e005730. doi: 10.1161/CIRCHEARTFAILURE.118.005730AbstractGoogle Scholar2. Shahu A, Herrin J, Dhruva SS, Desai NR, Davis BR, Krumholz HM, Spatz ES. Disparities in socioeconomic context and association with blood pressure control and cardiovascular outcomes in ALLHAT.J Am Heart Assoc. 2019; 8:e012277. doi: 10.1161/JAHA.119.012277LinkGoogle Scholar3. Tillman F, Kim J, Makhlouf T, Osae L. A comprehensive review of chronic heart failure pharmacotherapy treatment approaches in African Americans.Ther Adv Cardiovasc Dis. 2019; 13:1753944719840192. doi: 10.1177/1753944719840192CrossrefGoogle Scholar4. Patel N, Cushman M, Gutiérrez O, Howard G, Safford M, Muntner P, Durant R, Prabhu S, Arora G, Levitan E, et al. Racial differences in the association of NT-proBNP with risk of incident heart failure in REGARDS.JCI Insight2019; 4:129979. doi: 10.1172/jci.insight.129979.CrossrefGoogle Scholar5. Elliott W. Effectiveness of a Barber-Based Intervention for Improving Hypertension Control in Black Men: The BARBER-1 Study: A Cluster Randomized Trial. In: Gersh B, et al., ed. Yearbook of Cardiology. Philadelphia: Elsevier; 2011:95–97.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2020Vol 13, Issue 1 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.119.006642PMID: 31959015 Originally publishedJanuary 21, 2020 PDF download Advertisement SubjectsCardiovascular DiseaseHeart FailureQuality and OutcomesRace and EthnicityRisk Factors