The time is now: Identification and modification of disparities in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death in the United States (US) and worldwide [1]. While life expectancy and overall healthcare within the US have improved considerably in the past 100 years, racial, ethnic, and sex/gender inequalities continue to persist in terms of CVD risk factors, prevalence, treatment, and outcomes. Unfortunately, a substantial disparity in life expectancy between White and Black Americans has persisted for decades, driven predominantly by CVD and cardiometabolic conditions. Notably, the social determinants of health (SDOH)-where people live, work, play, and pray-are profound drivers of CVD burden and disparities. Furthermore, the global COVID-19 pandemic has only served to worsen these health disparities and the overall longevity imbalance. Despite the need to better understand potential unique aspects of CVD presentations and response to pharmacotherapy, inclusion of racial/ethnic groups in randomized clinical trials has been restricted by historical, scientific, institutional, socioeconomic, and cultural barriers. There is a moral and ethical need to correct the inequalities of care and inclusion in clinical research. Major randomized clinical trials of a wide-range of interventions have suboptimal diversity in enrollment but,nevertheless, serve as the evidential basis for guidelines and clinical practice [2].

This Special Issue for American Heart Journal Plus: Cardiology Research and Practice on disparities in cardiovascular morbidity and mortality seeks to further understand and address CVD disparities, which are persistent and significant across a wide-range of risk factors and outcomes. A collection of papers has been chosen to highlight unique elements and practical approaches to counter these disparities in cardiovascular health. The concepts and original research should prove interesting and relevant to all clinicians, regardless of specialty, who are involved in the care of patients, especially in racial/ethnic populations. Primordial prevention, before disease or even traditional risk factors are identified, is highlighted in a commentary investigating sugar sweetened beverages in adolescence. Community-clinical linkages are needed to address the SDOH, including in faith-based settings. Unique aspects of diagnosis and understanding of peripheral arterial disease in racial/ethnic populations and chronic kidney disease (CKD) are important to reveal unique CVD and associated target manifestations. In order to reverse and eliminate disparities, improving hypertension control and adherence are central. Moreover, a unique pilot study involving text-messaging with self-monitored blood pressure is highlighted in this special edition.

Primordial prevention is perhaps an essential first step in avoiding a growing CVD burden. Prior studies have shown a connection between cardiovascular health in childhood and CVD in adult life. As pediatric obesity rates continue to rise, the cardiometabolic health in U.S. adults continues to worsen. Vulnerable populations, including adolescents from specific ethnic/racial groups, have been targeted by commercial interests for increased sugar consumption. Nguyen and Ferdinand [3] explore national and international strategies to improve primordial prevention through the reduction in sugar-sweetened beverage consumption.

Collaborations between public health institutions and faith-based organizations have been proposed to successfully address multiple CVD risk factors and overall health. However, there are a limited number of studies that identify or evaluate neighborhood-level SDOH and the associated risks of HTN, diabetes, obesity and CVD. Alvarado, Hercules et al [7] evaluate and characterize neighborhood factors which may influence lifestyle behaviors for African American community church members within New Orleans, LA.

This Special Edition also includes results from a unique, federally-supported focus group pilot performing qualitative research conducted by Dr. Amber E. Johnson and her team from the University of Pittsburg School of Medicine. Social and behavioral themes were identified in participants who self-identified as Black race (n=15, 93.8%), highlighting the need for tailored clinical strategies to identify and manage atrial fibrillation.

Defining and revealing CKD, a powerful comorbid factor with CVD, is primarily assessed using an estimated glomerular filtration rate (eGFR). The most commonly used equations to calculate eGFR were derived from studies that included a limited number of Black participants and a binary racial variable, which categorized participants as either Black or all other races. However, race-based equations for eGFR are based on a flawed biological rationale and have no clinical or scientific validity. A new equation to calculate eGFR has been developed which does not incorporate race. Gillespie and Mohandas [6] explore the development of this new equation, its implication for cardiologists, and its potential impact on racial disparities.

In terms of morbidity and mortality, peripheral arterial disease (PAD) is the third leading cause of atherosclerotic CVD. The same racial/ethnic disparities present in overall atherosclerotic CVD are manifested in PAD prevalence. However, there are limited studies evaluating interventional data, rates of pharmacologic therapy and surgery, treatment-based survival, and adverse events. Nedunchezhian, Reddy et al [4] explore the disparities in PAD treatment outcomes within racial/ethnic populations.

Finally, HTN is the most prevalent and potent risk factor for CVD and the leading cause of morbidity and mortality around the world. The prevalence of HTN in non-Hispanic Black (NHB) adults is among the highest in the world, and uncontrolled HTN is the primary cause of the disparate CVD, heart failure, stroke, and CKD in NHB adults. A supportive social support system is associated with improved rates of medication adherence. Additionally, community-based interventions may be beneficial in improving patient adherence beyond the clinic and/or hospital setting. In a single cohort pilot, Ferdinand, Reddy et al [5] explore the effects that a Bluetooth enabled blood pressure cuff and bidirectional electronic messaging program—that connects patients to an interdisciplinary healthcare team—have on medication adherence and uncontrolled hypertension in a predominantly NHB population.

The road to health equity has been long and difficult. This Special Edition offers a wide range of publications, including commentary, systematic review and original research. Recognition of the impacts of the SDOH, defining disease states, and refining healthcare logistical challenges are required to improve outcomes across all populations, regardless of race/ethnicity, sex/gender, socioeconomic status, or geography.