Pub Date: Wednesday, Jan 25, 2023
Author: Nilay S. Shah, MD, MPH and Yvonne Commodore-Mensah, PhD, MHS, RN
Affiliation: Departments of Medicine (Cardiology) and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Johns Hopkins School of Nursing, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Cardiovascular disease (CVD) disparities in the United States have long been recognized. A fundamental step to mitigate CVD disparities in the United States is to recognize the patterns of how health and disease are experienced by populations. In the Heart Disease and Stroke Statistics 2023 Update, we and our co-authors aimed to explicitly quantify differences in CVD risk factors and outcomes among diverse communities.1 This effort was intentionally centered on health equity, motivated by the American Heart Association 2024 Health Equity Impact Goal that states "Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024 the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality."2
The 2023 Update delivers the most recent perennial reminder that we still have not realized the goal of cardiovascular health equity for many in the US and globally. The writing group of this year's Statistical Update focused on quantifying differences by age, sex, race, and ethnicity, similar to past years. This year the writers also intensified focus on quantifying differences on an array of social factors that are also related to health risk and outcomes: sexual orientation, gender identity, urbanization, and socioeconomic position. At this point, the authors of the Statement do not expect this effort to be comprehensive. We recognize that quantifying the differences in CVD risk factors and outcomes across identities and social factors is a necessary but insufficient step toward equity. A substantial component of such differences reflects preventable and unnatural disparities, that result from the additive and multiplicative influence of adverse social conditions. These social determinants, in turn, are partly – if not largely – a result of underlying structural factors such as racism and discrimination.3, 4
The statistics presented in the 2023 Update are a first step in a long journey to summarize what we know – and address what we do not know – about the state of CVD, especially among communities that remain underrepresented in clinical and epidemiological research. We acknowledge that the 2023 Update is demonstrably incomplete, despite the intention to broadly represent the US population, primarily due to insufficient or imperfect data. There are scarce data on cardiovascular health and CVD across many domains of health disparities. Examples include nativity status (US versus non-US-born), immigration status, disability, sexual orientation, and gender identity. Many observational studies and clinical trials do not adequately characterize race and ethnic groups, particularly for individuals who identify as Asian, Black, or Hispanic/Latino American. These populations are often underrepresented or inappropriately aggregated into overall race and ethnicity categories which masks substantial heterogeneity among subgroups (e.g., Asian Indian, Chinese, or Filipino Americans; Cuban, Mexican, or Puerto Rican Americans; Jamaican, African or Nigerian American). Further, the representation of some groups remains largely absent (such as American Indian or Alaska Native people) or mischaracterized (such as those who identify as Middle Eastern or North African). Mischaracterizing or erasing the diversity of populations threatens our ability to understand the sociocultural determinants that contribute to differences and disparities in health and disease, and to develop tailored strategies to improve the health of populations.
Moreover, the risk for CVD at the intersection of domains of identity and social determinants warrants attention. Although epidemiologists frequently categorize individuals into discrete groups, individuals may not neatly fall into such categories, or at the individual level several domains of social determinants may overlap to influence health. Consequently, individuals and populations may have unique experiences of disadvantage or advantage at the intersection of social identity and social determinants. For instance, the available statistics demonstrate that people who identify as Black, who identify as transgender, or those who live in the American South experience disproportionately worse CVD outcomes. The same data imprecisely characterize cardiovascular health and CVD outcomes among Black, transgender individuals who live in the American South. Such complexity of identity and social factors is inadequately reflected in contemporary data.
There remains considerable opportunity to understand how social and structural determinants, including access to health care services, housing stability, food insecurity, or social support influence cardiovascular health and CVD outcomes among subpopulations in the US. The dedication of investigators, institutions, and agencies who tirelessly work in communities to identify and address such factors to promote health must be recognized. Simultaneously, we submit that clinical trials and intervention studies, registries, and observational data to date only scratch the surface of how health and disease are experienced in the US. Given these considerable knowledge gaps, the AHA Heart Disease and Stroke Statistics 2023 are a starting point for identifying differences, disparities, and inequities in CVD, supplemented by several AHA Statements that address cardiovascular health and CVD among specific populations in more detail (Table). Sections of the 2023 Update in which statistics for specific populations are not listed are a clarion call to action for investigators, institutions, communities, and private and public funding agencies and organizations.
We can identify effective strategies to reduce and prevent CVD disparities only with intention at individual, health system, population, and policy levels to examine patterns of how health and disease are experienced among individuals and populations. Selected strategies to support this goal include:
- Revision and standardization of population-level data and new data collection to enhance our ability to examine risk and disease across intersecting identities and social factors.
- Expansion of multi-level data collection including neighborhood-level social determinants to facilitate development of actionable prevention and mitigation strategies.
- Deliberate efforts by clinical investigators and trialists to prioritize comprehensive social characterization of their enrollment population (e.g., race and ethnicity, sexual orientation and gender identity, urbanization, and socioeconomic position including income and educational attainment), followed by deployment of protocols to enroll participant samples that appropriately represent not only their eligible population but also reflect the diversity of the US.
- Dedicated funding from governmental and non-governmental organizations to include historically underrepresented populations in research (e.g., uninsured, those without stable housing, individual with limited English proficiency).
- Longitudinal investment in community-engagement infrastructure to build trust and align mutually beneficial missions between community, academic, and government stakeholders.
These opportunities are only a few avenues to enhance the accounting of CVD differences and disparities in the US and globally. All investigators, clinicians, institutions, funding organizations, and policymakers share responsibility to work toward these goals, because the 2023 Statistical Update makes one thing clear: to promote cardiovascular health for all, we must understand where we all start.
We thank the following individuals for their input during the preparation of this statement: Cheryl Anderson, PhD, MPH, MS; Dhruv Kazi, MD; Jared W. Magnani, MD, MSc; Seth Martin, MD, MHS; Connie Tsao, MD, MPH; Salim Virani, MD, PhD; and Sally Wong, PhD, RD.
- Martin SS, Palaniappan LP, Aday A, Anderson C, Arora P, Avery C, Baker-Smith C, Beaton A, Buxton A, Commodore-Mensah Y, Evenson K, Eze-Nliam C, Generoso G, Hiremath S, Ho J, Kazi D, Liu J, Ma J, Magnani J, Michos E, Mussolino M, Navaneethan S, Parikh N, Poudel R, Rezk-Hanna M, Roth G, Shah NS, St-Onge MP, Thacker E, Voeks JH, Virani S, Wang N, Wong N, Wong S, Heard D, Elkind M, Levine D, Almarzooq Z, Boehme A, Kalani R and Yaffe K. Heart Disease and Stroke Statistics - 2023 Update. Circulation. 2023;In press.
- Lloyd-Jones DM, Elkind M and Albert MA. American Heart Association's 2024 Impact Goal: Every Person Deserves the Opportunity for a Full, Healthy Life. Circulation. 2021;144:e277-e279.
- Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2003.
- Churchwell K, Elkind MSV, Benjamin RM, Carson AP, Chang EK, Lawrence W, Mills A, Odom TM, Rodriguez CJ, Rodriguez F, Sanchez E, Sharrief AZ, Sims M, Williams O and American Heart A. Call to Action: Structural racism as a fundamental driver of health disparities: A Presidential Advisory from the American Heart Association. Circulation. 2020;142:e454-e468.
Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge M-P, Thacker EL, Virani SS, Voeks JH, Wang N-Y, Wong ND, Wong SS, Yaffe K, Martin SS; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2023 update: a report from the American Heart Association [published ahead of print January 25, 2023]. Circulation doi: 10.1161/CIR.0000000000001123
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --