Equity and cardiovascular disease: time to take it seriously

Addressing disparities in diagnosis and management of cardiovascular disease (CVD) is crucial for improving population health and reducing discrimination-related deaths. Marginalised populations experience high rates of CVD and cardiovascular risk factors, mainly due to limited access to health care and to healthy foods and lifestyles. Education is inversely associated with the risk of CVD, and understanding the dangers associated with tobacco consumption and nutrition are key preventive factors. As now covered in a Series of papers in The Lancet Regional Health – Europe on inequalities and disparities in cardiovascular health, women,¹ people in racial or ethnic minorities,² people of advanced age,³ and patients with mental health disorders⁴ frequently face barriers to accessing quality health care. Moreover, the risk of a person facing discrimination increases with the number of factors involved (eg, if they are female, from a racial or ethnic minority, of advanced age, and have a mental disorders).

As highlighted in the Series papers, CVD has historically been understudied in women,¹ racial minorities,² older adults,³ and people with mental health conditions.⁴ This under-representation, a well-known problem in clinical trials, leads to scientific and clinical equipoise and inequities in care. In addition, symptoms related to CVD differ according to age and sex and can be influenced by race, ethnicity, cultural factors, and the presence of mental health disorders. So-called typical presentations are the common warning signs seen in young white men, without clinically significant mental health issues, whereas these presentations are frequently the exception in women or in older people.

Information regarding sex-specific CVD risk factors and prognostic markers is scarce, although sex hormones and pregnancy have a substantial effect on the cardiovascular system. Study of the effects of sex on CVD needs to be prioritised, awareness of the relevance on CVD in women needs to be raised, and primary and secondary prevention in females needs to be improved. Understanding and recognition of symptom presentation in women needs to improve, to reduce diagnostic delays and enable more accurate diagnosis and treatment, and CVD guidelines and recommendations need to be sex-specific, when evidence regarding differences in males and females is available. Women are frequently underdiagnosed, and the stereotype that CVD is a male condition is still common. In addition, sex might affect treatment effectiveness or complications; for instance, women treated with anthracyclines or radiation have higher risks of cardiotoxicity than men.⁵

CVD and its risk factors are more common among people in marginalised racial and ethnic groups, who often face barriers to accessing health care.⁶ To detect this discrimination, it is essential to register ethnicity and race, preferably by self-report. However, overreliance on race categories can lead to stereotyping and this information can be difficult to use without creating misunderstandings. Cultural and language barriers need to be overcome, and structured antiracism training during medical school and residence should be prioritised and deserves institutional support and funds.⁷

Population ageing is a reality worldwide, particularly in Europe. Older adults have a high prevalence of CVD and comorbidities that affect their diagnosis, treatment, complications, and prognosis. The effects of sexism and racism on diagnosis and management of CVDs are frequently acknowledged, but there is a clear need to raise awareness about the effects of ageism.⁸ Older adults tend to receive fewer diagnostic tests and interventions and their CVD-related symptoms are frequently misattributed to normal ageing. Moreover, factors such as financial limitations and social isolation can further exacerbate age-related inequalities. To address age-related discrimination, we need a comprehensive geriatric assessment, that is focused on patient-centred outcomes and addresses comorbidities, frailty, cognitive decline, and polypharmacy.

Mental health disorders are highly prevalent and increase the risk, morbidity, and mortality of CVD. Depression, anxiety, schizophrenia, and other psychiatric disorders are associated with poor treatment compliance, including not only drugs but also a lower adherence to healthy lifestyles. The fragmentation between mental and physical health care means that patients with mental issues frequently have less support, both from health-care systems and social networks, and more problems with access to health care or insurance coverage.⁹ In addition, symptoms as palpitations, chest pain, fatigue, or even dyspnea can be due to CVD or to mental disorders. Unfortunately, incorrect diagnosis of CVD is common in people with psychiatric disorders, as is incorrect diagnosis of psychiatric disorders in people with CVDs.⁴ Screening for conditions such as depression should be mandatory in patients with CVD. Finally, as education is inversely associated both with mental health problems and CVD, promoting learning could be an excellent way to prevent both conditions.¹⁰

Overall, there are many challenges in achieving equitable care for people with CVD and a firm commitment to change academic training, clinical practice, and research is needed. Strong evidence shows that women, people from racial or ethnic minorities, older adults, and patients with mental health disorders are under-represented, underdiagnosed, and undertreated. Developing and implementing interventions tailored to the specific needs and cultural contexts of different groups can improve outcomes. By prioritising equity, we can work towards a future where everyone has the opportunity to decrease their risk of dying due to CVD. The time has come to ensure that everyone is given the same access to CVD prevention and therapy.

Declaration of interests

No conflict of interest.