Cardiovascular disease and health disparities

Utibe R. Essien, MD, MPH

In late 2020, COVID-19 surpassed cardiovascular disease as the number one cause of death in the United States (https://bit.ly/35BbNNT). However, cardiovascular disease held that top spot for the greater part of the last century. Despite COVID-19’s rampage, cardiovascular disease remains an enormous health problem in the country. Of the millions of people suffering from this disease, a disproportionate number of them are Black and Brown people.

According to a 2017 Centers for Disease Control and Prevention report, African Americans were 20% more likely to die from heart disease than non-Latino/Hispanic whites. Black and Brown people also have disproportionately high rates for the major risk factors for cardiovascular disease—high blood pressure, obesity and diabetes. The inevitable question is why these health disparities exist.

Researchers like Utibe R. Essien, MD, MPH, assistant professor of medicine (Division of General Internal Medicine), University of Pittsburgh School of Medicine, are searching for answers to that question. He cites three categories that drive disparities in cardiovascular disease—at the patient level, provider level and system level. At the patient level, it is not only what patients eat or how much they exercise. It involves social determinants of health, which include patients’ environments, access to healthy foods and health care, public safety and educational and job opportunities. It is also important to know that the cause of these disparities is not biological.

“Black bodies don’t have more hypertension because of something in their genes, in their chemistry or their DNA,” says Dr. Essien. “It is these social drivers and how racism plays a role in these health disparities.”

Another driver of disparities in cardiovascular disease is seen at the provider level. Researchers have found that people of different races and ethnicities do not get the same health care. Recently, Dr. Essien and colleagues reported in JAMA Cardiology the results of a study that found Black people with atrial fibrillation (an irregular heartbeat) in the United States are less likely to receive medications that would help prevent stroke. Dr. Essien found that Black patients were 25% less likely to receive any oral anticoagulant drugs compared to white and Latino/Hispanic counterparts and 37% less likely to receive newer medications that are safer and easier to use. In addition, Dr. Essien says that data show Black patients are less likely to receive pain medication or be sent for cardiac catheterizations (a common test for chest pain to determine whether there is a clot in the heart).

“What’s going on in those conversations in the exam room?” says Dr. Essien. “What are some of the biases doctors are bringing when they see patients? How do these biases influence or affect the way patients are treated? We’ve seen time and time again that Black patients in particular, and minority patients more broadly, receive a lower quality of care.”

Disparities in cardiovascular disease are also driven at the system level. Dr. Essien points out that, even with the Affordable Care Act, millions of people lack health insurance and that many of those are people of color.

“We tell people to talk to their doctors about symptoms they have, but what if people don’t have a regular doctor?” says Dr. Essien. “With cardiovascular disease, it’s so important to get regular blood checks, to make sure you’re at a healthy weight and that your cholesterol levels are being screened. It’s critical to have regular access to a doctor, and that access comes with having health insurance. Health insurance, in this country, usually comes with having a job.”

Disparities are tied into other systemic issues—like where people live. Do people with cardiovascular disease live in a neighborhood with easy access to healthy food? Do they feel safe enough to go outside and exercise on their streets? Are the sidewalks in good shape so that people can go for walks or runs? Dr. Essien and colleagues recently published a study on pollution and atrial fibrillation. They found that, depending on where people live in Pittsburgh, patients who reside in more highly polluted areas are more likely to develop atrial fibrillation over time. Understanding these systemic issues as drivers of disparities, alongside patient- and provider-level factors, is essential.

Dr. Essien says that people can work on their own, also, to avoid cardiovascular disease in general by eating as healthfully as they are able to, exercise as best they can and get enough rest. And, for the millions of people who do have health insurance, they can engage in the health care system.

“The health disparities Black people face aren’t new,” says Dr. Essien. “But, if we’ve seen anything in the past year, it’s that we can engage and use our voices to make change. The same way we were able to ramp up resources around COVID-19 is the same way we need to approach health disparities as a whole to create bigger and bolder solutions.”

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