Role of Race and Ethnicity in Cardiovascular Health

Factors such as these, as well as differences in participant characteristics, make generalizations difficult. Dr Polonsky notes, for example, that many of the NOMAS participants were recent immigrants from the Dominican Republic, whereas many of the Hispanic participants in MESA were Mexican Americans who had been in the United States for at least 1 generation.

Overall, results suggest that “all racial and ethnic groups benefit equally downstream from attainment of ideal CV health, and thus addressing disparities in the achievement of ideal CV health metrics among minority groups would be an effective means for reducing disparities in clinical outcomes,” Dr Michos said. Despite these disparities, evidence-based screening and treatment guidelines should be used with all patients.

“Cardiovascular medications should be targeted to patients’ risk level or particular disease rather than race,” advised Dr Watson. There may be certain nuances pertaining to race or ethnicity that clinicians should be aware of. “While the benefits are generally not different by race, there are some side effects that are more common for certain medications in particular races and ethnicities,” including higher rates of cough with angiotensin-converting enzyme (ACE) inhibitors in Asians and greater incidence of angioedema with ACE inhibitors in African Americans.

Dr Michos added that ACE inhibitors and angiotensin receptor blockers appear to be less effective in blacks vs whites, so it is recommended that first-line antihypertensive therapies in black patients include a calcium channel blocker or thiazide-type diuretic instead of an ACE inhibitor.6

As another example, the risk for gestational diabetes is higher among Hispanic, South Central Asian, and American Indian women, and this does not appear to be fully explained by prepregnancy body mass index.7 This suggests a need for culturally sensitive approaches to screening and prevention.

Dr Watson believes there should be more diversity among participants in relevant studies: “Ideally, all clinical trials would have enough participants from a broad range of ethnicities in order to define the benefits and risks in all groups. Unfortunately, most clinical trials do not.” 

Given the multiple factors that may influence the race/CVD disparity, we “need a multifaceted approach for improving screening, awareness, and implementation of appropriate evidence-based recommendations for the 7 health metrics among minority groups,” Dr Michos stated. “Minority groups face more overall barriers toward attainment of ideal CV health. We need to figure out how to fix this.”

Dr Michos offered the following suggestions: culturally sensitive health education regarding prevention, the recruitment and training of more physicians who are underrepresented in medicine, and a greater focus on the interplay of genetics with environmental and social factors.

“There should be no reason that one’s race or ethnicity alone should pose a higher risk for worse CVD outcomes, and the Polonsky study suggests that if we can similarly improve the CV health metrics to ‘ideal’ across all racial and ethnic groups, they will have similarly low burden of subclinical and overt CVD,” said Dr Michos.

Related Articles

References

  1. Benjamin EJ, Blaha MJ, Chiuve SE, et al; for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603. doi:10.1161/CIR.0000000000000485
  2. American Heart Association. The 2020 impact goal. https://www.heart.org/idc/groups/heart-public/@wcm/@swa/documents/downloadable/ucm_425189.pdf. Accessed April 18, 2017.
  3. Muntner P, Abdalla M, Correa A, et al. Hypertension in blacks: unanswered questions and future directions for the JHS (Jackson Heart Study). Hypertension. 2017;69(5):761-769. doi:10.1161/HYPERTENSIONAHA.117.09061
  4. Polonsky TS, Ning H, Daviglus ML, et al. Association of cardiovascular health with subclinical disease and incident events: the multi-ethnic study of atherosclerosis. J Am Heart Assoc. 2017;6(3):e004894. doi:10.1161/JAHA.116.004894
  5. Dong C, Rundek T, Wright CB, Anwar Z, Elkind MS, Sacco RL. Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and Hispanics: the northern Manhattan study. Circulation. 2012;125(24):2975-2984. doi: 10.1161/CIRCULATIONAHA.111.081083
  6. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi :10.1001/jama.2013.284427
  7. Kim SY, England L, Sappenfield W, et al. Racial/ethnic differences in the percentage of gestational diabetes mellitus cases attributable to overweight and obesity, Florida, 2004-2007. Prev Chronic Dis. 2012;9:E88. doi:10.5888/pcd9.110249