Abstract
Racial-ethnic disparities exist in the prevalence and outcomes of heart failure (HF) and are presumed to be related to differences in cardiovascular risk factor burden and control. There is little data on stroke disparities among patients with HF or the factors responsible. We hypothesized disparities in stroke prevalence exist among patients with HF in a manner not fully explained by burden of cardiovascular disease. We analyzed data from the National Health and Nutrition Examination Survey (1999–2014). Cardiovascular profiles were compared by race/ethnicity. Using survey-weighted models, effect modification of the relationship between HF and stroke by race/ethnicity was examined adjusting for cardiovascular profiles. Of 40,437 participants, 2.5% had HF. The HF cohort had a greater proportion of White and Black participants (77% vs 74% and 15% vs 12%, respectively) and fewer participants of Hispanic ethnicity (8% vs 14%). Stroke was 8 times more prevalent in HF (19.6% vs 2.3%, <0.001). Among individuals with HF, race-ethnic differences were identified in the prevalence and mean values of vascular risk factors but were largely driven by higher rates in Black participants. There was significant interaction between HF and race/ethnicity; HF increased the odds of stroke over 7-fold in participants of Hispanic ethnicity (aOR: 7.84; 95% CI: 4.11–15.0) but to a lesser extent in Black and White participants (Black aOR: 2.49; 95% CI: 1.72–3.60; White aOR: 3.36; 95% CI: 2.57–4.40). People of Hispanic ethnicity with HF have a disproportionately higher risk of stroke in a manner not fully explained by differences in vascular risk profiles.
Keywords: Stroke, Heart failure, Race, Ethnicity, Disparities
INTRODUCTION
Heart failure is a growing epidemic and is likely to affect over 8 million adults in the US by 2030 [1]. The prevalence of heart failure in Black Americans, approximately 3.5% in adults, is higher than in any other race/ethnic group, though the prevalence in the Hispanic population closely follows [1,2]. The higher prevalence is further compounded by the higher rates of secondary complications and mortality in minorities with the disease [1–4]. Stroke is one of the leading causes of morbidity in patients with heart failure and more than doubles mortality [5,6]. There is little data on how race/ethnicity modifies this risk though previous literature offers evidence for disparities in the epidemiology of both heart failure and stroke. Specifically, higher rates of stroke and greater stroke severity are frequently cited in racial and ethnic minorities in the general population, and among patients with heart failure, Black and Hispanic patients experience higher mortality and faster rates of disease progression compared to patients of White race [1,2]. These findings have been largely attributed to population differences in cardiovascular risk factors [7]. However, growing evidence suggests disparities in the burden of cardiovascular disease may not fully account for the observed differences in cardiovascular outcomes, and there is growing appreciation for the clinical impact of social determinants on cardiovascular health. Social determinants of health (SDOH) are the conditions in which people are born, live, learn, work, play, and age that affect health and quality-of-life outcomes. These determinants include factors related to economic stability, educational access and quality, neighborhood and built environment, social and community context, and healthcare access and differences across these domains have been linked disparate cardiovascular outcomes. Here we investigated racial and ethnic differences in prevalent stroke among community-dwelling adults with and without heart failure using a large, nationally representative sample of the US population. We also explored the role population-based differences in cardiovascular risk profiles and SDOH serve in any observed disparities. We hypothesized racial/ethnic disparities in cardiovascular risk profiles contribute to but do not fully explain differences in stroke prevalence among patients with heart failure.
METHODS
Study Population and Study Design
For this cross-sectional analysis we used data of adult participants (≥18 years) from the National Health and Nutritional Examination Survey (NHANES). The NHANES collects data from the US civilian population using a complex four-stage sampling design. With the addition of sample weights, data from each cycle is intended to represent data from the entire US population [8]. For this cross-sectional study, we collected data from eight, 2-year cycles (16 years, from 1999–2000 to 2013–2014). Detailed descriptions of the survey design and procedures are available on the NHANES website (www.cdc.gov/nchs/nhanes.htm). Briefly, participants in NHANES were selected by using multistage probability sampling and data on nutrition and health were obtained by interview and physical and laboratory examinations. For each cycle, a representative sample of approximately 5,000 participants are selected from various US counties. All study participants provided informed consent before participation in the survey. As data were de-identified and publicly available, the Columbia University Institutional Review Board deemed this analysis exempt.
Survey Measures
Standardized questionnaires were used to assess self-reported demographic and social characteristics including age, sex, race/ethnicity, educational attainment, insurance status, and household income. We used poverty-income ratio (PIR), an index of income in relation to family need, derived from household income and federally established poverty thresholds (based on family size and annual changes in cost of living [tracking Consumer Price Index]) (9). PIR was categorized into quartiles (lowest, Q1 [PIR: 0–1.35]; Q2 [1.36–2.59]; Q3 [2.60–4.59], and highest, Q3 [≥4.60]). This analysis focused only on non-Hispanic White, non-Hispanic Black, and Hispanic participants because of small sample sizes for other race/ethnic groups. Medical conditions and vascular risk factors including heart failure, hypertension, diabetes, hyperlipidemia, and smoking history were assessed through questionnaires. History of stroke was obtained through questionnaire as an affirmative response to the question “Has a doctor or other health professional ever told you that you had a stroke”. In addition, measures of glycated hemoglobin A1c (HbA1c) and serum low density lipoprotein (LDL), measurements of weight and height (for body mass index, BMI), and systolic and diastolic blood pressure (SBP, DBP) were included for analysis. Three consecutive BP readings were attempted, and mean BP measurement was calculated. Active smoking was defined as “smoked ≥ 100 cigarettes in lifetime” and “smokes currently” and obesity defined as BMI ≥ 30 kg/m2. Along with questionnaire responses, presence of diabetes was determined by HbA1c > 6.5%, presence of hypertension as mean SBP > 140 or DBP > 80 mm Hg across all 3 readings, and hyperlipidemia as LDL >100 md/dL.
Statistical Analyses
All analyses were conducted using specialized procedures to account for sample weighting and the complex multistage probability design. NHANES-provided sample weights were adjusted to account for the combination of data from the eight 2-year cycles included and for the sub-sampling of adult (≥18 years) participants. Participants with missing data related to heart failure status, race/ethnicity, or history of stroke were excluded. Baseline characteristics were compared between participants with and without heart failure and across race/ethnic groups using t-tests, chi-square tests, Kruskal-Wallis tests, and Wilcoxon rank-sum tests where appropriate. Trend analysis of stroke prevalence was performed using logistic regression. Regression models were used to examine the association between heart failure and race/ethnicity on the outcome of prevalent stroke, first by including heart failure and race/ethnicity as independent predictors and then by including their cross-product term (race/ethnicity*heart failure). Statistical significance for effect modification was assessed by likelihood ratio testing with the interaction P value of <0.05 considered significant. Statistical models included the following participant variables: age, sex, heart failure status (where appropriate), race/ethnicity (where appropriate), educational attainment, insurance status, poverty income ratio, and vascular risk factors as dichotomous variables (presence of diabetes, hypertension, hyperlipidemia, obesity and smoking status). All data and guidance on analytical approaches are publicly and freely available from the US Centers for Disease Control and Prevention’s National Center for Health Statistics and can be accessed at https://www.cdc.gov/nchs/nhanes/index.htm. All analyses were conducted in STATA version 17.0 (StataCorp, College Station, Texas).
RESULTS
Baseline Characteristics
Participant demographics, social and health and characteristics are summarized in Table 1. The overall study cohort consisted of 40,437 participants representing 198,924,722 US adults (Figure 1); mean age was 46.9 (SE 0.2) years and 52% were women. Most participants were of White race (74%), followed by Hispanic ethnicity (14%) and Black race (12%). The prevalence of heart failure was 2.5%. Compared to those without heart failure, the heart failure cohort had a larger proportion of participants of White race (77% vs 74%) and Black race (15% vs 12%) and fewer participants of Hispanic ethnicity (8% vs 14%). There was a higher prevalence of hypertension (44% vs 33%), diabetes (41% vs 13%), and obesity (52% vs 36%) within the heart failure cohort but a similar prevalence of hyperlipidemia (91% vs 89%). Stroke was over 8 times more prevalent in the heart failure cohort (19.6% vs 2.3%), and the prevalence of stroke remained relatively stable across the 16 years of analysis in both subgroups (P for trend: without heart failure= 0.275, with heart failure=0.228) Figure 2.
Table 1.
NHANES Participants Demographic and Clinical Characteristics (1999–2014)
| Patient Characteristics | Total Weighted n = 198,924,722 | No HF Weighted n = 194,013,609 | HF Weighted n = 4,911,112 |
|---|---|---|---|
| Weighted frequency (%) or Mean (SE) | Weighted frequency (%) or Mean (SE) | Weighted frequency (%) or Mean (SE) | |
| Age, years | 46.9 (0.2) | 46.4 (0.2) | 66.4 (0.5) |
| Sex | |||
| Male | 48% | 48% | 50% |
| Female | 52% | 52% | 50% |
| Race/Ethnicity | |||
| White | 74% | 74% | 77% |
| Black | 12% | 12% | 15% |
| Hispanic | 14% | 14% | 8% |
| Education | |||
| < High School | 6% | 6% | 16% |
| High School/GED | 13% | 12% | 20% |
| > High School | 81% | 82% | 64% |
| Poverty Income Ratio | |||
| Lowest Quartile | 21% | 21% | 33% |
| 2nd Quartile | 21% | 21% | 29% |
| 3rd Quartile | 24% | 24% | 21% |
| Highest Quartile | 34% | 34% | 18% |
| Insurance Status | |||
| Insurance | 81% | 81% | 93% |
| No Insurance | 19% | 19% | 7% |
| Vascular Risk Factors | |||
| CAD | 3% | 3% | 40% |
| HTN | 33% | 33% | 44% |
| Mean SBP | 122.5 (0.19) | 122.3 (0.19) | 130.1 (0.77) |
| Mean DBP | 71.1 (0.15) | 71.2 (0.15) | 67.3 (0.55) |
| Diabetes | 14% | 13% | 41% |
| A1c | 5.5 (0.01) | 5.5 (0.01) | 6.2 (0.04) |
| Hyperlipidemia | 89% | 89% | 91% |
| LDL | 117.0 (0.38) | 117.3 (0.39) | 105.7 (2.04) |
| Obesity | 36% | 36% | 52% |
| BMI | 28.7 (0.06) | 28.6 (0.06) | 31.4 (0.32) |
| Active Smoker | 23% | 23% | 19% |
| Stroke | 2.8% | 2.3% | 19.6% |
BMI, body mass index; CAD, coronary artery disease; DBP, diastolic blood pressure; HTN, hypertension; LDL, low density lipoprotein; SBP, systolic blood pressure
Figure 1.
Study Flowchart
Figure 2.
Stroke prevalence over time stratified by heart failure status (1999–2014)
No Heart Failure: weighted n = 194,013,609
Heart Failure: weighted n = 4,911,112
No Heart Failure: Ptrend = 0.275
Heart Failure Ptrend = 0.228
Vascular Risk Factors Across Race/Ethnicities in Participants with Heart Failure
Figure 3 illustrates the vascular risk factor profiles of study participants with heart failure across race/ethnic groups. Among individuals with heart failure, racial and ethnic differences were identified in prevalent hypertension (P < 0.001), diabetes (P < 0.001), and obesity (P = 0.004) but were largely driven by rates in Black participants. Only rates of diabetes differed between Hispanic and White adults with heart failure (46.0% vs 37.6%, P = 0.013). Figure 4 illustrates the distribution of vascular risk factors as continuous measures among individuals with heart failure across race/ethnicities. Differences in SBP, BMI and hemoglobin A1c values were observed across race/ethnic groups but were again driven by differences among participants of Black race. There was no difference in median values of BMI, hemoglobin A1c, systolic blood pressure, or LDL between White and Hispanic participants with heart failure.
Figure 3.
Prevalence of Vascular Risk Factors in Heart Failure by Race/Ethnicity
White participants with heart failure: weighted n = 3,787,261
Black participants with heart failure: weighted n = 718,092
Hispanic participants with heart failure: weighted n = 405,759
HTN, hypertension; HLD, hyperlipidemia
Figure 4.
Vascular Risk Factors in Participants with Heart Failure by Race/Ethnicity
White participants with heart failure: weighted n = 3,787,261
Black participants with heart failure: weighted n = 718,092
Hispanic participants with heart failure: weighted n = 405,759
BMI, body mass index; LDL, low density lipoprotein; SBP, systolic blood pressure
Stroke Prevalence Across Race/Ethnicities in Participants with and without Heart Failure
We identified significant interaction between heart failure and race/ethnicity on stroke prevalence (P = 0.001 for interaction). Figure 5 illustrates the crude prevalence of stroke in participants with and without heart failure, stratified by race. Among those without heart failure, Black participants had the highest prevalence of stroke (3.2%), followed by adults of White race (2.4%) and Hispanic ethnicity (1.2%). Among those with heart failure, Hispanic participants had the highest prevalence of stroke (21.6%), followed by White (20.0%) and Black (16.9%) adults. Among participants of Hispanic ethnicity, heart failure was associated with a greater than 7-fold increase in risk of stroke (aOR: 7.84; 95% CI: 4.11–15.0) after adjusting for vascular risk factors (Table 2). Heart failure also increased risk of stroke among individuals of Black and White race but to a lesser and similar extent (Black aOR: 2.49; 95% CI: 1.72–3.60; White aOR: 3.36; 95% CI: 2.57–4.40). After additionally adjusting for education, insurance status, and poverty income ratio, the odds of stroke were significantly reduced in White participants (aOR: 2.99; 95% CI: 2.30, 3.90), while the risk of stroke in participants of Black race and Hispanic ethnicity was not significantly changed.
Figure 5.
Prevalence of Stroke Stratified by Heart Failure Status and Race/Ethnicity
White participants without heart failure: weighted n = 143,119,253
White participants with heart failure: weighted n = 3,787,261
Black participants without heart failure: weighted n = 23,090,856
Black participants with heart failure: weighted n = 718,092
Hispanic participants without heart failure: weighted n = 27,803,500
Hispanic participants with heart failure: weighted n = 405,759
Pinteraction=0.001
Table 2.
Adjusted Odds of Stroke in Heart Failure Across Race/Ethnic Groups
| No Heart Failure aOR (95% CI) | Heart Failure aOR (95% CI) | |
|---|---|---|
| Model 1 | ||
| White | Ref | 3.36 (2.57, 4.40) |
| Black | Ref | 2.49 (1.72, 3.60) |
| Hispanic | Ref | 7.84 (4.11, 15.0) |
| Model 2 | ||
| White | Ref | 2.99 (2.30, 3.90) |
| Black | Ref | 2.48 (1.70, 3.63) |
| Hispanic | Ref | 7.32 (3.86, 13.9) |
Model 1: Age, sex, vascular risk factors: obesity, diabetes hypertension, hyperlipidemia, smoking status
Model 2: Model 1 + insurance status, education, and poverty income ratio
White participants without heart failure: weighted n = 143,119,253
White participants with heart failure: weighted n = 3,787,261
Black participants without heart failure: weighted n = 23,090,856
Black participants with heart failure: weighted n = 718,092
Hispanic participants without heart failure: weighted n = 27,803,500
Hispanic participants with heart failure: weighted n = 405,759
DISCUSSION
In this nationally representative sample, stroke was over 8 times more prevalent in adults with heart failure compared to those without (19.6% vs 2.3%), a difference that remained relatively stable over the 16 years of analysis. However, the relationship between heart failure and stroke differed across race/ethnicities. Among Hispanic individuals, heart failure increased risk of stroke over 7-fold, more than twice the effect observed in Black and White participants. These differences were not fully explained by population differences in comorbid cardiovascular disease or levels of risk factor control and was only modestly attenuated by the socioeconomic factors of education, insurance status, and income. Our findings confirm disparities in neurologic outcomes in heart failure, particularly among individuals of Hispanic descent, and highlight gaps in our understanding of the factors responsible.
Racial disparities in stroke are well-established [1,10–13]. Black individuals tend to have stroke at a younger age, experience greater post-stroke disability, and have higher stroke mortality [11,14]. In a population-based study estimating temporal trends in stroke incidence, declining rates of first-ever stroke were observed among White Americans while rates in Black Americans remained unchanged—a trend likely to exacerbate these existing disparities [15]. Data on stroke risk in the Hispanic population is less robust and frequently conflicting [11,14,16,17]. However, previous reports have identified higher rates of recurrent stroke and relatively stagnant rates of post-stroke survival compared to non-Hispanic Whites [15,18]. Disparities in cardiovascular outcomes also exist in heart failure. Annual heart failure incidence is 2 – 3 times higher in Black Americans compared to White Americans before age 75, and Black and Hispanic patients with heart failure tend to be younger and have higher rates of readmission [1–4]. Previous reports have also identified higher rates of secondary renal insufficiency and greater prevalence of abnormal ejection fraction in Hispanic patients with heart failure compared to patients of White race, usually implying worse prognosis and higher risk of cardiovascular complications [19]. Though previous studies have demonstrated increased risk of complications and worse outcomes in minorities with heart failure, few studies have examined differences in risk of stroke. In a single-center review of 168 consecutive adult patients with severely reduced left ventricular ejection fraction, Black race was associated with 2.3-fold increased odds of silent cerebral infarct on brain imaging [20]. And in subgroup analysis of the 222 cases of stroke identified in the Digitalis Investigation Group (DIG) trial, non-White race was associated with increased stroke severity and post-stroke mortality among patients with chronic heart failure and normal sinus rhythm [21].
The reason for these disparities is unclear. Previous studies have implicated population differences in cardiovascular risk factors as a major contributor to observed differences in heart failure outcomes [2]. In our study however, racial-ethnic differences in risk of stroke in patients with heart failure were observed even after controlling for vascular risk factors. In addition, within the heart failure cohort the only difference in risk factors observed were among individuals of Black race. The profound increase in risk of stroke among patients with heart failure of Hispanic ethnicity despite similar vascular risk profiles suggests factors other than cardiovascular health may be driving disparities. Socioeconomic factors and community awareness may also play a role [22, 23, 24]. In the Atherosclerosis Risk in Communities (ARIC) study, having smaller social networks (i.e., contact with fewer family members, friends, and neighbors) was associated with a 44% higher risk of incident stroke over a follow-up period of 18.6 years, even after controlling for demographics and other relevant risk factors [22]. In another single center study of 144 stroke survivors, Hispanic individuals scored lower on a test of both stroke symptoms and appropriate response to those symptoms compared to non-Hispanic White survivors and were less often aware of tPA as an acute treatment [23]. And in another analysis of the community-based multi-ethnic Northern Manhattan Study (NOMAS), an increased risk of stroke was identified in their primarily Caribbean-Hispanic population compared to non-Hispanic Whites which was largely explained by socioeconomic proxies [10]. In our analysis, risk of stroke was significantly reduced after adjusting for insurance status, education, and poverty income ratio in White participants but was largely unchanged in minority populations, suggesting different social determinants of health may not effect patients with cardiovascular disease equally. The relationship between SDOH, race-ethnicity, and cardiovascular outcomes is likely complex and multifactorial, involving societal factors difficult to account for in epidemiologically-based studies including the effects of provider biases, cultural norms, and structural racism.
Our findings that Black participants with heart failure had greater prevalence of hypertension, diabetes, obesity, and hyperlipidemia when compared to White participants is consistent with prior reports [2,3,4]. However, it is unclear why lower rates of stroke were observed in Black patients with heart failure despite the greater burden of multiple vascular risk factors. One explanation may be the effects of competing risks and survival bias. Multiple studies have associated Black race with greater stroke mortality in the general population and worse cardiovascular outcomes in heart failure, which together would likely limit the number of Black stroke survivors with heart failure available for study participation [1,2].
Our study has important limitations. First, the cross-sectional nature of our analysis limits inferences that can be made regarding the influence of current risk factor profiles on the incidence of prior strokes. As a cross-sectional analysis our study is also limited in the assessment of the long-term consequences of vascular risk factors on stroke risk. As the NHANES survey limits participation to noninstitutionalized, community-dwelling adults, it is unlikely to capture individuals with either more advanced cardiac disease or with more severe stroke deficits that require long-term institutional care. Further, specific details regarding heart failure disease severity such as ejection fraction or NYHA functional class as well as other important vascular confounders including atrial fibrillation were unavailable and differences in these factors across race/ethnic groups may have also affected study outcomes. In addition, several other variables of interest including heart failure status and stroke history were determined by self-report, which likely underestimates the true prevalence of these diseases, particularly among minority patients as previously reported [25]. The self-reporting of race/ethnicity also increases the susceptibility of our data to misclassification. However, these race/ethnic designations have been shown to correspond well with biological ancestry as derived from ancestry-informative markers for these populations [26–28].
Key strengths of our analysis pertain to the use of a large nationally representative dataset, inclusion of multiple detailed measures of cardiovascular disease, and population-based representation of the three major race/ethnic groups in the United States. The inclusion of eight 2-year survey cycles of NHANES data increased the robustness of our estimates and our large sample size allowed for the detection of effect modification at the level of race/ethnicity, a feature lacking in many prior reports analyzing the clinical impact of heart failure on cardiovascular outcomes among minority groups. To our knowledge, our study is one of the first to assess the relationship between heart failure and stroke across race/ethnic groups and evaluate the contribution of comorbid cardiovascular disease on its differential effect. Our findings confirm disparities in neurologic outcomes in heart failure, particularly among individuals of Hispanic descent and highlight the need for continued investigations into the non-clinical drivers of these race/ethnic variations.
Heart failure substantially increases the risk of stroke. This effect is most pronounced in adults of Hispanic ethnicity but in a manner not fully explained by differences in comorbid cardiovascular disease or degree of risk factor control. As the National Institute of Neurological Disorders and Stroke recently emphasized their commitment to supporting outcomes research identifying causes of race/ethnic disparities in neurological disease, our study fills an important gap by highlighting the disparate effect of a major stroke risk factor and potential contributor to the well-known disparities in cardiovascular outcomes. Further work is needed to identify the non-clinical drivers of these disparate effects to improve health equity and outcomes in minority populations.
Highlights.
Stroke is over 8 times more prevalent in adults with heart failure
The relationship between heart failure and stroke may differ across race/ethnicities
Hispanic individuals with heart failure may experience greater risk of stroke than patients with heart failure of other racial/ethnic groups
Racial/ethnic differences in stroke risk among patients with heart failure is not fully explained by cardiovascular risk profiles
Funding
The study was supported by the National Institute of Neurological Disorders and Stroke (NINDS R01 NS121364) (JZW), National Institute on Aging (NIA P30AG059303) (CI), and Bristol Myers Squibb Foundation (CI).
Footnotes
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Competing Interests
The authors declare that they have no conflict of interest.
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