A recent study revealed that Black Americans experienced nearly 800,000 excess cardiovascular deaths from 2000 to 2022, highlighting the impact of health disparities and systemic racism.
Key takeaways:
- Between 2000 and 2022, there were almost 800,000 excess cardiovascular deaths among Black Americans.
- The excess CV deaths translate to 24 million additional years of life lost.
Perspective from Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA
Reflecting disparities in cardiovascular care, there were nearly 800,000 excess CV deaths among Black Americans between 2000 and 2022, according to a “report card” published in the Journal of the American College of Cardiology.
“Our study reveals that Black Americans, because of their higher cardiovascular mortality rates compared with white Americans, have suffered almost 800,000 excess deaths, which translates to about 24 million additional years of life lost between 2000 and 2022,” Harlan M. Krumholz, MD, SM, FACC, the Harold H. Hines, Jr. Professor of Medicine at Yale School of Medicine and the incoming editor-in-chief of JACC, said in a press release. “This staggering figure highlights the critical need for systemic changes in addressing cardiovascular inequities.”
Excess CV deaths
Krumholz and colleagues used the CDC WONDER database to determine causes of death among non-Hispanic Black and non-Hispanic white Americans between 2000 and 2022. The causes of death defined as CV were ischemic heart disease, hypertension, cerebrovascular disease and HF. They then calculated age-adjusted mortality rates for each of the four CV causes of death and determined excess age-adjusted mortality rates by subtracting the estimated age-adjusted mortality rates of white people from the age-adjusted mortality rates of Black people. They calculated years of life lost, defined as the number of years a person would have lived had they not died when they did, by multiplying the 5-year age group crude mortality rate by the life expectancy of white people, and determined excess years of life lost by subtracting the estimated years of life lost of white people from the estimated years of life lost of Black people.
The researchers estimated that between 2000 and 2022, there were 779,387 excess CV deaths and 23.7 million excess years of life lost due to CVD in Black Americans compared with white Americans; 362,887 of the excess deaths and 11.2 million of the excess years of life lost were in Black women. The excess deaths and years of life lost spiked during the COVID-19 pandemic, according to the researchers.
Harlan M. Krumholz
“Despite the triumphant reduction in cardiovascular morbidity and mortality over the last 50 years, those declines evolved at racially disproportionate rates resulting in not just health inequities, but life inequities,” Krumholz and colleagues wrote. “The disparities are evident across different subcategories, including ischemic heart disease, hypertension, cerebrovascular disease and heart failure. Moreover, the sharp increases during the pandemic indicate the specific vulnerability of this group during a public health crisis and the need to mitigate this risk in future pandemics.”
‘Urgent call for health care redesign’
Jennifer H. Mieres
In a related editorial, Jennifer H. Mieres, MD, FACC, senior vice president of the Center for Equity of Care at Northwell Health and chair of the ACC Diversity and Inclusion Committee, and colleagues wrote: “This report card lays bare the longstanding and persistent racial disparities in CV health. Even though it was not directly studied in this analysis, published data reveal that 80% of health outcomes are related to factors other than the clinical encounter. These social drivers of health (SDoH, also known as the social determinants of health) dramatically impact mortality. Structural racism leads to negative SDoH, which in turn produces poor health outcomes. How can one thrive without good health? The report … is significant at this time and serves as a reminder of the urgent call for health care redesign to integrate an equity lens to quality CV care. Advancing equity in CV health and health care is possible, actionable and should be a top priority of the entire CV community, including health care systems and CV teams.”
References:
- JACC report card highlights inequities in CV care, death rates. https://www.acc.org/About-ACC/Press-Releases/2024/06/18/13/44/JACC-Report-Card-Highlights-Inequities-in-CV-Care-Death-Rates. Published June 18, 2024. Accessed June 18, 2024.
- Mieres JH, et al. J Am Coll Cardiol. 2024;doi:10.1016/j.jacc.2024.06.005.
PERSPECTIVE
Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA
Unfortunately, the data released in the JACC report are not new, but confirm the longstanding unfortunate and unacceptable disparities in CV morbidity and mortality across race/ethnicity that we see in the United States. The white/Black mortality gap was described 20 years ago by the Institute of Medicine and has been persistent, mainly driven by CVD.
What is the solution? It will not be easy. Limited access to therapy and adverse social determinants of health — where people work, live, play and pray — have a profound impact on CVD. New risk calculators are now attempting to integrate, based on ZIP code analyses, the social determinants of health and CVD burden.
We also have intrinsic inequality in the health care delivery system. Persons with no or limited insurance often don’t seek care until later stages of the disease process. At that time, increased obesity, physical inactivity, cigarette use and, most importantly — especially in the Black population — uncontrolled hypertension, manifest themselves in end-organ damage, including heart attacks, cerebrovascular accidents, HF and chronic kidney disease. We have known extensively for years that the poor control of these CV risk factors, complicated by the inherent inequalities of the health care delivery system, leads to worse outcomes at a higher cost. Although the United States, compared with other industrialized, Westernized societies, and also Japan, spends more per dollar per capita on health care, our health care spending has not translated to improved life expectancy. In fact, the life expectancy in the United States is shorter than that seen in comparable Westernized industrialized societies.
We know that race is a social construct, despite nuances of how disease presents, such as higher lipoprotein(a) in persons of African and South Asian descent, or forms of cardiomyopathy such as transthyretin-mediated amyloidosis (ATTR-CM). Nevertheless, the overwhelming reason for these disparate rates in CV morbidity and mortality are structural inequities — the social determinants and, unfortunately, intrinsic bias on how we as clinicians treat patients. The data are important to report, but simply reporting this important, persistent inequity will not solve the problem. We need to ensure that all patients are treated equally, regardless of race/ethnicity, sex/gender, socioeconomic status, geography, disability or ability. If we do not do this, we will not have an equitable society.
As I wrote in an editorial in 2022 (Ferdinand KC. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2022.10.007), if we want to tackle the elevated atherosclerotic CVD risk in the Black American population, we should maximize our understanding of social determinants of health, address uncontrolled major risk factors, employ coronary artery calcium scoring in patients at intermediate risk and identify patients with elevated Lp(a), while minimizing skin color or self-identified race, unmeasured genetic factors, low HDL as a marker of increased risk and high HDL and low triglycerides as markers of decreased risk.
The NIH and NHLBI have been attempting to address whether community interventions would be a step forward in reducing disparities in CV morbidity and mortality. We know of the powerful effects of the Los Angeles Black barbershop study conducted by the late Ronald G. Victor, MD (Victor RG, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1717250). There are now efforts to see if using community health workers and nurse practitioners to advance health practices in community and nontraditional settings can help patients control risk factors and stem the tide of end-stage disease where patients present to EDs at major institutions with the need for dialysis, admission for HF, treatment for acute stroke or interventions for acute MI. It has not yet been proven that this will be effective, but community-based interventions is one hopeful step forward.
Universal health care is a necessity. Health care is a right. If we don’t give access to excellent evidence-based care for all patients, we will pay the price with admissions and readmissions for what is largely preventable in terms of CVD.
Educating youth about health-seeking behavior, including avoiding excess sodium, saturated fat and processed foods, will also go a long way. The lateGerald S. Berenson, MD, showed in the Bogalusa Heart Study decades ago that atherosclerosis, including conventional risk factors such as dysglycemia, obesity and hypertension, are not simple manifestations of adulthood, but start in the adolescent and preteen years. We need to invigorate efforts to help our children understand the benefits of healthy lifestyle and the need to seek medical care early in disease processes, and not wait until manifestations of symptoms of disability.
We as clinicians cannot be passive and stand by. We all pay for this excess cost in terms of medical care, treating patients with end-stage renal disease at a cost of $90,000 to $120,000 per year, which is three times more in the Black population than predicted by population alone. Or treating patients with premature HF and recurrent admissions for HF. Or treating patients with stroke, the most chronic, costly cause of disability in the United States, again disparate in the Black population and mainly driven by poorly controlled hypertension.
We know what to do. Now the challenge is to implement what we know.
Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA
Healio | Cardiology Today Editorial Board Member
Gerald S. Berenson Endowed Chair in Preventative Cardiology
Professor of Medicine
Tulane University School of Medicine
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