Race and Stroke Risk in Atrial Fibrillation

Kabra et al. (1) have reported the increased 12-month risk of stroke in black Medicare recipients with atrial fibrillation (AF) compared with that in whites. Adding black ethnicity, or African-American race, to the CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Prior stroke, transient ischemic attack [TIA], or thromboembolism, Vascular disease, Age 65–74 years, Sex category [female]) algorithm predicted increased stroke risk; the authors subsequently recommended anticoagulation therapy for stroke prevention. Their principal finding, that black race is associated with increased stroke risk in AF, is undoubtedly important. However, we suggest closer consideration of the place of race-based practices in patient care.

As noted in the editorial (2), race is largely a social construct. Designating racial groups based on sociodemographics or self-identification is a social practice without genetic basis (3). Once we acknowledge the challenges to the scientific validity of race and ethnicity, we are compelled to consider the sociodemographic factors that mediate racial differences in cardiovascular disease outcomes. To our knowledge, no race-based biological mechanisms explain the increased risk of strokes (or other adverse outcomes, such as coronary heart disease, heart failure, and mortality) (4) in blacks with AF compared to that in whites. We would assert that racial differences in outcomes and disparities in treatment do not stem inherently from race; rather, they constitute the legacy of race as a foremost social determinant of health.

The findings by Kabra et al. (1) are important because they remind us of the continued presence of race in cardiovascular and other outcomes, and the distance we have yet to go in providing race-blind health care. Our view is that labeling people as high risk because they are black does not address the fundamental causes that perpetuate racial disparities. In striving for optimized medical care, we must evaluate social determinants that shape access to care and implementation of prevention strategies and their efficacy to impact health outcomes and address inequities. We need models for understanding racial disparities that incorporate environmental and genetic indicators and that can more completely explain differences in health outcomes (5).