This cohort study investigates associations of psychosocial stress from racism and childhood or adolescent abuse with later risk of incident heart failure among Black women in the US.
Key Points
Question
Is psychosocial stress associated with heart failure in Black women in the US?
Findings
In this cohort study of 48 320 Black women, perceived discrimination in each of 3 domains—employment, housing, or interactions with police—was associated with increased heart failure risk, with the highest risk observed with discrimination across multiple domains. Frequent sexual assault in childhood or adolescence was associated with elevated heart failure risk, with partial attenuation after adjustment for body mass index.
Meaning
The findings suggest psychosocial stress may contribute to disparities in heart failure incidence and outcomes among Black women, potentially acting through traditional risk factors such as body mass index.
Abstract
Importance
Black women are disproportionately susceptible to developing heart failure and display more severe morbidity and mortality compared with White women. Factors contributing to excess heart failure risk among Black women remain incompletely understood.
Objective
To characterize the associations of components of psychosocial stress, including experiences of interpersonal racism and childhood or adolescent abuse, with heart failure development among Black women.
Design, Setting, and Participants
This was a prospective cohort study with baseline assessment in 1997 for racism and 2005 for abuse variables and median follow-up of 24 years (IQR, 16-24 years), ending in 2023. The cohort included Black Women’s Health Study participants who were free from heart failure at baseline. Participants resided across all geographic regions of the US.
Exposures
Participants completed questionnaires on perceived interpersonal racism, including questions on everyday interactions and perceived discrimination in employment, housing, or with police. Self-reported type and frequency of childhood or adolescent abuse were also ascertained.
Main Outcome and Measures
Incident heart failure, ascertained via questionnaire. Cox proportional hazards regression was used to assess prospective associations of psychosocial stress exposures with incident heart failure.
Results
Among 48 320 Black women (median age at baseline, 40 years [IQR, 32-48 years]; median baseline body mass index [BMI], 27 [IQR, 24-32]), 1343 heart failure events were observed. Perceived discrimination in employment, housing, or interactions with police was associated with increased heart failure risk, with the highest risk observed in the 11% of participants who experienced discrimination in all 3 domains (hazard ratio [HR], 1.27 [95% CI, 1.06-1.52] in multivariate models). The HR for highest (vs lowest) quartile of daily racism score was 1.23 (95% CI, 1.05-1.45) in age-adjusted analyses but was attenuated to 1.04 (95% CI, 0.88-1.22) after adjustment for clinical risk factors. Frequent childhood (HR, 1.54; 95% CI, 1.16-2.06) or adolescent (HR, 1.86; 95% CI, 1.34-2.58) sexual assault (≥4 times) was associated with elevated heart failure risk, with some attenuation after multivariable adjustment, although adolescent abuse remained significant (HR, 1.44; 95% CI, 1.04-2.00). In mediation analysis, BMI was observed to be a partial mediator (proportion mediated, 19.6%-35.9%) of the associations of childhood or adolescent sexual abuse (≥4 times) with incident heart failure.
Conclusions and Relevance
In this cohort study of US Black women, perceived interpersonal racism and sexual abuse in childhood or adolescence were associated with increased heart failure risk decades later; as these exposures are more prevalent among Black than White women, they may represent risk factors that contribute to heart failure disparities. Future studies are needed to elucidate mechanisms linking psychosocial stress to heart failure, such as changes in BMI.
Introduction
Cardiovascular disease (CVD) remains the leading cause of death among women in the US.1 Black women are twice as likely as White women to die at a young age from CVD.2 Black women are particularly susceptible to developing heart failure and having severe disease-associated morbidity after heart failure diagnosis.3,4,5,6,7 Prior studies have suggested that several factors, including genetics, higher burden of traditional risk factors, health care disparities, and the intersectionality of gender and racial bias, contribute to higher heart failure risk for Black women.8,9,10 However, these studies relied on comparisons between Black women and women from other racial and ethnic groups and had limited power to detect heart failure risk factors particularly relevant to Black women. Additionally, historical underrepresentation of women and of racial and ethnic minority groups in cardiovascular research has delayed the pace of mechanistic understanding of these disparities.1
A prior finding that differences in heart failure risk among Black and White women appear to persist after accounting for the higher burden of traditional risk factors highlights an important gap in understanding and underscores the need to identify additional heart failure risk factors in Black women.11 Black women may be more likely to experience high levels of psychosocial stress in multiple domains, including early life, employment, finances, and relationships,12,13,14 as a result of both interpersonal and structural racism.13,14,15 Psychosocial stress is increasingly recognized as a critical contributor to CVD risk, especially in women.11,16 It is theorized to act through detrimental effects on both biological pathways and health behaviors.17,18,19 Accordingly, exposure to repeated stressors is hypothesized to contribute to long-term alterations in vascular and hemodynamic physiology that may be particularly relevant to heart failure development.20 However, the associations of specific domains of psychosocial stress with heart failure risk among Black women and how they relate to traditional heart failure risk factors remain incompletely understood.
To assess how different domains of psychosocial stress relate to future heart failure risk among Black women, we studied nearly 50 000 women from the Black Women’s Health Study (BWHS) with standardized ascertainment of prior experiences of perceived interpersonal racism and childhood or adolescent abuse and over 20 years of follow-up. We hypothesized that higher occurrence of stressful life events would be associated with increased heart failure risk (eFigure in Supplement 1).
Methods
Study Sample
This cohort study used data from the BWHS, a prospective cohort study of 59 000 Black women from across the US.21,22,23 Age at enrollment in 1995 was 21 to 69 years, with a median age of 38 years; follow-up concluded in 2023. Participants resided in 17 states across the US, and approximately 95% were born in the US. Biennial follow-up questionnaires garner information on demographics, socioeconomic factors, lifestyle factors, and medical conditions. Follow-up is complete for approximately 85% of potential person-years. The current study was approved by the institutional review board of the Boston University Medical Campus. Informed consent was implied by the return of questionnaires. This report follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Assessment of Psychosocial Stress
We analyzed 2 components of psychosocial stress: perceived interpersonal racism and childhood or adolescent abuse. Perceived interpersonal racism was assessed at the 1997 questionnaire and the 2009 questionnaire, as previously reported.22,23 This assessment had 2 main components. The first was designed to quantify experiences with perceived racism in everyday interactions. Participants reported how often they experienced the following due to their race: (1) Do you receive poorer service than other people at restaurants or stores? (2) Do people act as if they think you are not intelligent? (3) Do people act as if they are afraid of you? (4) Do people act as if they think you are dishonest? and (5) Do people act as if they are better than you? Each question was answered on a scale of 1 (never), 2 (a few times per year), 3 (once per month), 4 (once per week), or 5 (almost daily). The sum of the scores for each of the 5 questions was calculated and assigned as a composite score for each participant (total possible score range of 5-25). The second component of the perceived interpersonal racism questionnaire quantified experiences with perceived racism in employment, housing, and interactions with police, with binary (yes-no) responses. Childhood and adolescent abuse were assessed via questionnaire in 2005. For each period (childhood and adolescence), exposure was classified as no abuse, physical abuse only, exposure to genitals without sexual assault, sexual assault 1 to 3 times, or sexual assault 4 or more times.
Incident Heart Failure and Covariate Assessment
Incident heart failure cases were ascertained through biennial BWHS questionnaires, upon which participants reported interval medical diagnoses. Any report of heart failure diagnosis was considered to constitute incident heart failure if the participant had no prior reported heart failure diagnosis. Among a subsample of 51 heart failure cases with sufficient records for full adjudication using Framingham Heart Study criteria,24 40 cases (78%) were confirmed as probable or definite heart failure.
Established heart failure risk factors were chosen a priori as covariates. All covariates for perceived interpersonal racism were taken from the 1997 questionnaire. Because childhood or adolescent abuse data were collected at the 2005 questionnaire, all covariates for those analyses were taken from 2005. Missing covariate data were treated as indicator variables in analyses.25 Missingness in our study’s sample was low (1% or less) for body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), educational level, and smoking and was somewhat higher (8%-12%) for neighborhood socioeconomic status (SES) and vigorous physical activity. Details on covariate assessment are included in the eMethods in Supplement 1.
Statistical Analysis
Prospective associations of psychosocial stress exposures with incident heart failure were assessed with time-to-event analyses using Cox proportional hazards regression. Participants contributed person-time from completion of the first exposure assessment (1997 for racism and 2005 for abuse) to a self-reported diagnosis of heart failure, loss to follow-up, or end of the follow-up period (2023). The daily racism score was analyzed in quartiles, and questions on discrimination were analyzed individually and as the number of “yes” responses. A linear test for trend was performed to evaluate whether there was increased risk of heart failure with increased exposure. Childhood and adolescent abuse were reported and analyzed separately. Multivariable models were adjusted for age and subsequently for potential heart failure risk factors, including BMI, level of education attained (high school graduate, some college, college graduate, or some graduate education), US geographic region, neighborhood SES, vigorous physical activity, smoking, diabetes, hypertension, and prior myocardial infarction.
Because perceived interpersonal racism was assessed again on the 2009 questionnaire, we performed a secondary analysis using a time-varying approach in which exposure and covariates were updated using values from 2009 for individuals with available assessments at that time. In other secondary analyses, we assessed whether associations of psychosocial stressors with incident heart failure differed by age of disease onset by stratifying according to person-time at risk before age 55 years and at age 55 years or older. Because BMI may function as an effect modifier or a mediator, we conducted additional analyses, including (1) stratifying by BMI (<30 or ≥30) during person-time at risk and (2) a mediation analysis evaluating whether BMI served as a mediator of associations between childhood or adolescent abuse and heart failure. Mediation analysis was not performed on the association between perceived interpersonal racism and BMI, as the temporality of this association was less certain. We performed mediation analysis based on Cox proportional hazards regression using the CMAverse package in R, version 4.5.1 (R Project for Statistical Computing), which uses a counterfactual mediation and bootstrap procedure, which was set to 1500 iterations.26
A 2-sided P value less than .05 was considered statistically significant. All analyses were performed using R, version 4.5.1.
Results
The study sample for analyzing experiences of interpersonal racism included 48 320 Black women with a median age at baseline of 40 years (IQR, 32-48 years) and a median baseline BMI of 27 (IQR, 24-32) who were free of heart failure at baseline (Table 1). Most women had completed at least some college, and there was representation throughout geographic regions of the US and across neighborhood SES scores. Perceived discrimination was prevalent across multiple domains, with 58% of participants reporting experiencing discrimination in employment, 36% in housing, and 23% in interactions with police; 11% of participants reported discrimination in all 3 of these domains (Table 2).
Table 1. Characteristics of Black Women’s Health Study Participants.
| Characteristic | Participants, No. (%) (N = 48 320)a |
|---|---|
| Age, median (IQR), y | 40 (32-48) |
| BMI | |
| Median (IQR) | 27 (24-32) |
| Category | |
| <25 | 16 787 (35) |
| 25 to <30 | 15 658 (32) |
| 30 to <35 | 8318 (17) |
| ≥35 | 7146 (15) |
| Missing | 411 (1) |
| Educational level, y | |
| ≤12 | 8538 (18) |
| 13-15 | 17 239 (36) |
| 16 | 11 772 (24) |
| ≥17 | 10 698 (22) |
| Missing | 73 (<1) |
| US region of residence | |
| Northeast | 12 792 (26) |
| South | 15 209 (31) |
| Midwest | 11 153 (23) |
| West | 9064 (19) |
| Otherb | 102 (<1) |
| Neighborhood SES, quintile | |
| 1 (Most deprivation) | 8405 (17) |
| 2 | 8767 (18) |
| 3 | 8941 (19) |
| 4 | 9041 (19) |
| 5 | 9144 (19) |
| Missing | 4022 (8) |
| Vigorous physical activity, h/wk | |
| 0 | 21 437 (44) |
| <3 | 16 872 (35) |
| ≥3 | 8986 (19) |
| Missing | 1025 (2) |
| Smoking status | |
| Never | 31 125 (64) |
| Former | 9606 (20) |
| Current | 7585 (16) |
| Missing | 4 (<1) |
| Type 2 diabetes | 2548 (5) |
| Hypertension | 9272 (19) |
| Myocardial infarction | 625 (1) |
| Age at heart failure onset (n = 1343) | |
| <35 y | 19 (1) |
| 35-44 y | 123 (9) |
| 45-54 y | 358 (27) |
| 55-64 y | 371 (28) |
| 65-75 y | 326 (24) |
| >75 y | 146 (11) |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); SES, socioeconomic status.
Baseline characteristics of participants at the 1997 examination cycle are shown.
Included US military addresses.
Table 2. Association of Interpersonal Racism With Risk of Heart Failure Among 48 320 Participants.
| Response | Cases/person-years | HR (95% CI) | |||
|---|---|---|---|---|---|
| Model 1a | P value for linear trendb | Model 2c | P value for linear trendb | ||
| Interpersonal racism in everyday interactions | |||||
| Daily racism score, quartile | |||||
| 1 (Lowest) | 281/163 370 | 1 [Reference] | .02 | 1 [Reference] | .86 |
| 2 | 385/258 956 | 0.98 (0.84-1.15) | 0.97 (0.83-1.13) | ||
| 3 | 330/265 374 | 0.94 (0.80-1.10) | 0.89 (0.76-1.05) | ||
| 4 | 347/230 083 | 1.23 (1.05-1.45) | 1.04 (0.88-1.22) | ||
| Discrimination | |||||
| Employment | |||||
| No | 489/381 306 | 1 [Reference] | .003 | 1 [Reference] | <.001 |
| Yes | 854/536 477 | 1.17 (1.05-1.31) | 1.17 (1.05-1.31) | ||
| Housing | |||||
| No | 805/588 572 | 1 [Reference] | 1 [Reference] | ||
| Yes | 538/329 211 | 1.05 (0.94-1.17) | 1.12 (1.01-1.26) | ||
| Police interactions | |||||
| No | 998/700 619 | 1 [Reference] | 1 [Reference] | ||
| Yes | 345/217 164 | 1.19 (1.06-1.35) | 1.16 (1.03-1.32) | ||
| All 3 domains | |||||
| No to all | 358/274 605 | 1 [Reference] | 1 [Reference] | ||
| Yes to 1 | 423/308 001 | 1.07 (0.93-1.24) | 1.08 (0.94-1.25) | ||
| Yes to 2 | 372/230 680 | 1.16 (1.01-1.35) | 1.25 (1.08-1.45) | ||
| Yes to 3 | 190/104 497 | 1.28 (1.07-1.53) | 1.27 (1.06-1.52) | ||
Abbreviation: HR, hazard ratio.
Model 1 was adjusted for age.
The P value for linear trend test estimates the change in risk per each additional discrimination domain.
Model 2 was adjusted for age, body mass index, educational level, US region of residence, neighborhood socioeconomic status, vigorous physical activity, smoking, diabetes, hypertension, and prior myocardial infarction.
Over a median follow-up period of 24 years (IQR, 16-24 years), 1343 heart failure events occurred. In age-adjusted models, individuals in the highest quartile of daily racism score had a higher risk of developing heart failure compared with the lowest quartile (hazard ratio [HR], 1.23; 95% CI, 1.05-1.45) (Table 2). With additional adjustment for demographic and clinical risk factors, there was no longer an association, with an HR of 1.04 (95% CI, 0.88-1.22) for the highest vs lowest quartile of daily racism score. Sequential nested models indicated that BMI was the covariate primarily responsible for attenuation of the effect estimate.
Experiences of discrimination in employment, housing, and with police were each associated with a statistically significant increase in heart failure risk in fully adjusted models (Table 2). The HRs were higher for discrimination in more than 1 domain (1.25 [95% CI, 1.08-1.45] and 1.27 [95% CI, 1.06-1.52] for women who experienced discrimination in 2 domains and in all 3 domains, respectively) compared with none. A time-varying analysis that updated exposure to interpersonal racism and discrimination in employment, housing, or interactions with police with questionnaire responses in 2009 yielded similar results (eTable 1 in Supplement 1).
A substantial number of heart failure events occurred at younger ages, with 37% of events occurring before the age of 55 years (Table 1). In analyses stratified by age (<55 or ≥55 years), the HRs for heart failure associated with interpersonal racism were similar in each age group (eTable 2 in Supplement 1). We also conducted analyses stratified by BMI. For unfair treatment due to race in all 3 domains, the HR for heart failure was higher among women with BMI less than 30 (HR, 1.56; 95% CI 1.17-2.09) than among women with higher BMI (HR, 1.16; 95% CI 0.92-1.47) (eTable 3 in Supplement 1).
Among 31 420 women who completed questionnaires on childhood or adolescent abuse in 2005 (65% of the total cohort), there were 725 heart failure events over a median follow-up of 16 years (IQR, 14-16 years). In this subsample, 52% of participants answered yes to any form of childhood abuse, 42% reported any form of adolescent abuse, 6% reported experiencing sexual assault 4 or more times during childhood, and 4% reported experiencing sexual assault 4 or more times during adolescence (Table 3). In age-adjusted models, a history of experiencing sexual assault 4 or more times in either childhood or adolescence was associated with an increased risk of future heart failure (childhood: HR, 1.54 [95% CI, 1.16-2.06]; adolescence: HR, 1.86 [95% CI, 1.34-2.58]). With multivariable adjustment, the HRs were attenuated, but the association with exposure to adolescent abuse remained statistically significant (HR, 1.44; 95% CI, 1.04-2.00). In age-stratified analyses, we observed that an association between experiencing childhood or adolescent sexual assault 4 or more times and heart failure was present in women aged 55 years or older but not in women younger than 55 years (eTable 4 in Supplement 1). In analyses stratified by BMI, the HR for heart failure among women experiencing sexual assault 4 or more times during adolescence was 1.48 (95% CI, 0.77-2.84) in women with BMI less than 30 and 1.51 (95% CI, 1.03-2.23) in women with BMI of 30 or greater (eTable 5 in Supplement 1). In mediation analyses (Figure), we observed BMI to be a partial mediator (proportion mediated, 19.6%-35.9%) of the associations of childhood and adolescent abuse with incident heart failure.
Table 3. Association of Childhood or Adolescent Abuse With Incident Heart Failure Among 31 420 Participants.
| Response | Cases/person-years | HR (95% CI) | |
|---|---|---|---|
| Model 1a | Model 2b | ||
| Childhood abuse | |||
| No abuse | 346/204 188 | 1 [Reference] | 1 [Reference] |
| Physical abuse only | 186/117 722 | 1.00 (0.84-1.20) | 0.98 (0.82-1.18) |
| Exposed to genitals | 47/29 272 | 1.05 (0.77-1.42) | 1.04 (0.77-1.41) |
| Sexual assault 1-3 times | 90/52 759 | 1.21 (0.96-1.53) | 1.08 (0.85-1.36) |
| Sexual assault ≥4 times | 56/25 906 | 1.54 (1.16-2.06) | 1.24 (0.92-1.65) |
| Adolescent abuse | |||
| No abuse | 413/249 280 | 1 [Reference] | 1 [Reference] |
| Physical abuse only | 106/63 490 | 1.14 (0.92-1.42) | 1.04 (0.84-1.29) |
| Exposed to genitals | 54/32 314 | 1.12 (0.84-1.49) | 1.07 (0.80-1.43) |
| Sexual assault 1-3 times | 112/69 386 | 1.08 (0.88-1.34) | 0.94 (0.76-1.17) |
| Sexual assault ≥4 times | 40/15 377 | 1.86 (1.34-2.58) | 1.44 (1.04-2.00) |
Abbreviation: HR, hazard ratio.
Model 1 was adjusted for age.
Model 2 was adjusted for age, body mass index, educational level, US region of residence, neighborhood socioeconomic status, vigorous physical activity, smoking, diabetes, hypertension, and prior myocardial infarction.
Figure. Mediation Analysis Evaluating the Association Between Experiencing Sexual Assault 4 or More Times, Body Mass Index (BMI), and Heart Failure.
Analysis was adjusted for age. Indirect effects represent the BMI-mediated effects and direct effects represent the effects independent of BMI. HR indicates hazard ratio.
Discussion
In this study, we evaluated the prospective associations between different domains of psychosocial stress that disproportionately affect Black women and incident heart failure in a large sample of Black women that included heterogeneity across geographic location, SES, educational level, and cardiovascular risk profiles. Experiences of discrimination in employment, housing, or interactions with the police and a history of adolescent sexual abuse were both associated with increased heart failure risk after accounting for demographic and clinical risk factors. Our sample was notable for a large number of heart failure events occurring in women before age 55 years, which aligns with other cohorts, such as CARDIA, which found that the incidence of heart failure before the age of 50 years in Black participants was 20 times the incidence in White participants.27 However, in the current study, the associations of interpersonal racism or discrimination with heart failure were consistent among women with younger and older age of heart failure onset. Taken together, our findings indicate that psychosocial stress exposures may be contributors to the disproportionate heart failure risk observed among US Black women.
The current investigation builds on and extends a body of evidence supporting a link between psychosocial stress and CVD that may be particularly relevant in women. In the INTERHEART study, which evaluated risk factors for myocardial infarction worldwide, experiencing stress at work or at home was an important risk factor for myocardial infarction overall, but the risk was greater in women.28 Studies have also demonstrated that stress is associated with deleterious effects on cardiac structure, particularly in women.29 Caring for a sick spouse has been associated with almost double the risk of CVD mortality,30 and experiencing daily marital tension was shown to be associated with a 3-fold increased risk of recurrent CVD events.31 Among Hispanic women, higher rates of psychosocial stress were found to have independent associations with several CVD risk factors.32 On the other hand, a study from the Multi-Ethnic Study of Atherosclerosis (MESA) found no association of anxiety and depressive symptoms with heart failure, which may reflect differing experiences and stressors across the various racial groups represented in MESA.33 These studies, along with a wealth of other data, led the European guidelines for CVD prevention to recognize psychosocial stress as an independent risk factor for CVD, with a magnitude of risk equal to that attributed to traditional CVD risk factors.34,35
Prior studies from the BWHS have also shown an association between perceived interpersonal racism and both coronary heart disease23 and incident stroke.22 Similar to our study, these reports also observed modest attenuation with risk factor adjustment, and associations were more often observed for experiences of discrimination in employment, housing, or interactions with police than for the daily racism score. To our knowledge, the BWHS is the largest cohort in the US composed solely of Black women, which allows for the assessment of exposures that may vary among Black women (rather than between Black and White women). Herein, we observed that experiences of interpersonal racism were associated with a higher risk of developing heart failure. This association displayed a dose effect for experiences of discrimination in employment, housing, and interactions with police, with the highest risk observed in the 11% of the sample who reported discrimination in all 3 contexts. This finding was similar with childhood or adolescent sexual assault, with the highest risk observed in the 4% to 6% of women who reported assault 4 or more times. Notably, neighborhood SES and educational level did not attenuate the association between psychosocial stress and heart failure in our study. While these factors and other social determinants of health have previously been implicated in heart failure disparities,36 prior studies have relied primarily on comparisons between racial groups, potentially resulting in residual confounding and misclassification.37
The link between obesity and heart failure risk is well established, particularly in heart failure with preserved ejection fraction (EF).38,39 We observed obesity to be a partial mediator of the association of childhood or adolescent abuse with heart failure risk, suggesting that the mechanism of association may act at least in part through obesity. Psychosocial stress is known to contribute to obesity via potential biological pathways (eg, activation of the hypothalamic-pituitary-adrenal axis and stimulation of leptin and ghrelin40) as well as psychological effects, such as the propensity to consume high-calorie or high-sugar foods, via its interaction with reward pathways in the brain.41 In the BWHS, perceived interpersonal racism was previously shown to be associated with obesity, particularly among women who reported repeated experiences at multiple questionnaire cycles.19 The interrelatedness between obesity, heart failure risk, and psychosocial stress in the BWHS suggests that obesity may represent a key pathway through which stress contributes to heart failure risk, and this finding warrants further study.
The relative consistency of effect sizes within the BWHS showing associations of perceived interpersonal racism and discrimination with stroke,22 coronary heart disease,23 and now heart failure suggests that the primary pathways may be shared across different forms of CVD. In addition to promoting obesity and insulin resistance, chronic stress activates the sympathetic nervous system, leading to endothelial dysfunction and promoting inflammation.17 Proteomic profiles of new-onset heart failure from the UK Biobank found that pathways associated with incident heart failure were related to neutrophil degranulation, immune response, and inflammatory processes.38 Although these pathways were similar in women and men, when present in women, they were associated with a higher risk of disease.
Strengths and Limitations
The present investigation has several important strengths, including a prospective cohort design and a large sample of Black women with wide distribution of prior exposure to psychosocial stressors and long-term follow-up. There are also notable limitations that should be considered. Our primary outcome of heart failure was ascertained by self-report, with the potential for misclassification. However, we reviewed medical records for 51 women, among whom heart failure was confirmed to be probable or definite in 78%, which is consistent with other large epidemiologic cohorts,42 providing confidence in our self-reported outcome. Perceived interpersonal racism and childhood or adolescent abuse are complex and sensitive experiences, and numerous factors may influence participants when they recall these experiences, which makes our exposure inherently subject to measurement error. However, all analyses used prospective data, such that heart failure events included in the analyses occurred after participants reported on these exposures. In addition, the questionnaires used in this study are validated for use (Cronbach α, 0.74; test-retest reliability coefficient, 0.7023) and have been previously applied and published in studies of US Black women.19 We adjusted for several important cardiovascular risk factors; however, we were unable to adjust for other potentially relevant factors such as diet, sleep, and chronic kidney disease. As with all observational studies, this cohort study is subject to residual confounding from unmeasured or incompletely measured risk factors, and our findings may be influenced by the healthy volunteer effect. In addition, due to the size and design of our cohort, we did not have access to information on heart failure phenotypes, including echocardiographic information, heart failure subtype (preserved EF vs reduced EF), or heart failure biomarkers.
Conclusions
In this cohort study of psychosocial stress and heart failure among Black women in the US, we found that several domains of psychosocial stress were associated with incident heart failure. Our findings underscore that different aspects of psychosocial stress disproportionately experienced by Black women may portend elevated heart failure risk independent of sociodemographic risk factors, identifying additional risk factors that may underlie the disparity in heart failure risk among Black women. Further studies are needed to understand the biological pathways underlying this risk and how it may vary by heart failure phenotype.
eMethods
eFigure. Conceptual Framework
eTable 1. Time-Varying Analysis of Psychosocial Stress and Heart Failure Among 46 775 Participants
eTable 2. Association of Interpersonal Racism With Risk of Heart Failure, Stratified by Age
eTable 3. Association of Interpersonal Racism With Risk of Heart Failure, Stratified by Body Mass Index
eTable 4. Association of Childhood or Adolescent Abuse With Risk of Heart Failure, Stratified by Age
eTable 5. Association of Childhood or Adolescent Abuse With Risk of Heart Failure, Stratified by Body Mass Index
eReferences
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods
eFigure. Conceptual Framework
eTable 1. Time-Varying Analysis of Psychosocial Stress and Heart Failure Among 46 775 Participants
eTable 2. Association of Interpersonal Racism With Risk of Heart Failure, Stratified by Age
eTable 3. Association of Interpersonal Racism With Risk of Heart Failure, Stratified by Body Mass Index
eTable 4. Association of Childhood or Adolescent Abuse With Risk of Heart Failure, Stratified by Age
eTable 5. Association of Childhood or Adolescent Abuse With Risk of Heart Failure, Stratified by Body Mass Index
eReferences
Data Sharing Statement
