Circulation July 19, 2022 Issue

This week, please join Associate Editors Mercedes Carnethon and Karol Watson, as well as Guest Editor Fatima Rodriguez as they present the 2nd annual Disparities Issue. Then join Rishi Wadhera and Ashley Kyalwazi as they discuss their article "Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019."

Dr. Mercedes Carnethon:

Well, good day listeners. I'm Mercedes Carnethon, and I'm joined by my fellow editors, Karol Watson, and Fatima Rodriguez, Associate Editor and Guest Editor for Circulation. And we'd like to welcome you to Circulation on the Run, for our second annual disparities issue. We have a lot of articles to discuss today, many of which we'll summarize, but we encourage you to access the issue and read the articles. First off, Fatima, I believe you have a paper to discuss.

Dr. Fatima Rodriguez:

Sure thing, Merci. My first paper is a thought provoking article by Nilay Shah, and co-authors from Northwestern University, that examine factors associated with the racial gap in premature cardiovascular disease.

Dr. Fatima Rodriguez:

This study used data from a well-known cardiac cohort, that aims to identify factors that begin in young adulthood and predict the development of future coronary artery risk. The objective of this study was to examine the relative contributions of clinical versus social factors, in explaining the persistent black/white gap in premature cardiovascular disease. After following around 5,000 black and white study participants for a median of 34 years, black men and women had a higher risk of premature cardiovascular disease. After controlling for multi-level individual and neighborhood level factors measured in young adulthood, the racial differences in premature cardiovascular disease were attenuated.

Dr. Fatima Rodriguez:

The authors found that the greater contributors to this racial disparity were not only clinical factors, but also neighborhood and socioeconomic factors. The relative explanatory power of each of these factors varied by men and women. This is really noteworthy, since we spent so much of our time in clinical medicine, focusing on identifying and managing traditional risk factors. But in reality, these structural factors and inequities are critically important to address, and contribute to differences in clinical risk factors downstream.

Dr. Mercedes Carnethon:

Thank you so much, Fatima. That was a really excellent summary. And now, I'm turning to you, Karol. I'd love to hear what you're going to be talking about today.

Dr. Karol Watson:

I'd like to discuss the paper, Association of Neighborhood Level Material Deprivation with Atrial Fibrillation Care in a Single-Payer Healthcare System Population Based Cohort Study. This is by Dr. Abdel-Qadir and colleagues.

Dr. Karol Watson:

So in this study, the author sought to determine whether there was an association between neighborhood material deprivation, by that we mean, inability to attain the basic needs of life and clinical outcomes, in individuals with atrial fibrillation. The kicker here is, they did this in an area with universal healthcare. So they wanted to see, if you took away the differences between the ability to see a physician or get your drugs paid for, if you would see any disparities.

Dr. Karol Watson:

So they performed a population based cohort study, individuals over the age of 66 years of age with atrial fibrillation, in the Canadian province of Ontario. They have universal healthcare there, and full drug coverage for anyone over 65. The primary exposure was neighborhood material deprivation. That's a metric used to estimate the inability to attain basic material needs, like healthy foods, safe housing. Neighborhoods were categorized by quintile, from the least deprived, quintile one, to the most deprived, quintile five. They find that, among about 350,000 individuals with atrial fibrillation, their mean age was 79, and about half of them were women. Those in the most deprived neighborhoods, quintile five, had a higher prevalence of cardiovascular risk factors and non-cardiovascular work comorbidity, relative to those who were in the least deprived areas.

Dr. Karol Watson:

Even after adjusting for all the confounders, they found that those in the most deprived neighborhoods had higher hazards of death, stroke, heart failure, and bleeding, relative to those in the least deprived neighborhoods. They also found that, despite having universal healthcare and drug coverage, those in the most deprived neighborhoods were less likely to visit a cardiologist, less likely to receive rhythm control intervention, such as ablation, and have worse outcomes.

Dr. Karol Watson:

And then, the accompanying editorial by Utibe Essien, he reminds us that intervening only on traditional markers of access, like health insurance and drug costs, may not be sufficient to achieve health equity. We have to address all of the structural needs that make people unable to get good help. Further, he points out that, the association between atrial fibrillation and neighborhood deprivation is very likely true with other cardiovascular conditions, as well.

Dr. Karol Watson:

So, Merci and Fatima, this just reminds us again, that addressing all the social determinants of health are necessary to achieve the best health outcomes.

Dr. Mercedes Carnethon:

Thanks so much, Karol. I really appreciate that summary of that important piece, focusing on a different domain of disparity. My first paper is an excellent piece, led by one of my favorite other associate editors at Circulation, Dr. Wendy Post, from Johns Hopkins University. And I see a familiar name on here. That's yours, Karol. You two are joined by an all-star list of authors, to describe race and ethnic differences in all-cause in cardiovascular mortality, in the multi-ethnic study of atherosclerosis.

Dr. Mercedes Carnethon:

MESA is a longitudinal cohort study that launched in 2000, and recruited just over 6,800 adults who identified as black, white, Hispanic, and Chinese. While the study participants were initially free from cardiovascular disease, over an average of 16 years of follow up, 364 participants died from cardiovascular disease. There are a number of novel findings in this paper that led our editor-in-chief to select it as his pick of the issue.

Dr. Mercedes Carnethon:

The finding that really stands out to me is, how much of an influence the social determinants of health had on black versus white disparities in cardiovascular mortality. In fact, after adjusting for socioeconomic status, the disparities were nearly eliminated. Other critically important findings are that, the oft described Hispanic paradox of lower cardiovascular mortality in Hispanics, as compared with white adults, was demonstrated in this population. And finally, we have longitudinal data on Asians living in the United States. Asian participants in MESA had similar rates of cardiovascular disease mortality as their white counterparts. There's so much to learn in this well designed cohort study, and so many hypotheses about how social determinants and structural racism influence the disparities that we see.

Dr. Mercedes Carnethon:

So Fatima, I'd like to turn to you next. What else do you have to share?

Dr. Fatima Rodriguez:

Thank you, Merci. My second paper is a research letter for my home institution of Stanford University, led by my colleague, Dr. Shoa Clarke, discussing how race and ethnicity stratification for polygenic risk course, may mask disparities among Hispanic individuals.

Dr. Fatima Rodriguez:

This study used data from the Million Veteran Program, to determine how self-identified race and ethnicity impact the performance of polygenic risk scores in predicting coronary artery disease.

Dr. Fatima Rodriguez:

The investigators found, that the current polygenic risk scores predict coronary artery disease similarly well in Hispanic and non-Hispanic white individuals. However, what I found most interesting, is that there was so much more heterogeneity among Hispanic individuals as measured by K-Means clustering, than among non-Hispanic white individuals. And this study really confirms that there is much more heterogeneity within populations than between populations. And this is particularly true as we think of the extreme diversity of Hispanic populations. Lumping Hispanic populations into one category, may mask important differences in cardiovascular risk prediction outcomes, and even the notions of the Hispanic paradox that you just discussed, Merci.

Dr. Mercedes Carnethon:

I appreciate you bringing that up again, because there are so many different nuances to the observations that we see in these studies. But I'll keep moving, because we have an embarrassment of riches in this wonderful issue. So Karol I'll turn back to you.

Dr. Karol Watson:

Thanks, Merci. The next paper I'd like to discuss, is an On My Mind piece by Peter Liu and colleagues, and they entitle it, Achieving Health Equities in the Indigenous Peoples of Canada, Learnings Adaptable for Diverse Populations. Now the author's note that, lessons learned about addressing health disparities from indigenous peoples in Canada, can offer a lot of new lessons for other populations where there are similar disparities. They begin by offering historical perspective, and they say that, most of the health to disparities for the indigenous populations originate from early colonization, in dismantling of the sociocultural economic educational and health foundations, the indigenous communities had historically.

Dr. Karol Watson:

It's true that, that is true in a number of different countries. This is data from Canada, but we can see similar things in the United States. With the recognition of the historical and ongoing social health inequities, the Canadian government initiated what they call, the Truth and Reconciliation Commission, to recommend a path towards reconciliation, to create best practices for engaging indigenous populations.

Dr. Karol Watson:

For instance, in Canada, any health research or implementation program, requires the direct engagement of indigenous communities and their elders. They have to try to develop culturally safe environment, including what they say, quote unquote, anti-racism and cultural safety education for all, both indigenous and non-indigenous populations. They want to really respect community values, customs and traditions, including the access to traditional foods, and healing practices, and the support from elders. So they really are making it a very important point, that cultural sensitivity is absolutely critical to engaging these populations. You want to jointly collect data whenever available, to track progress and outcomes. And they offer many examples of successful programs developed using these principles, such as the Diabetes and My Nation program, in British Columbia, or the mobile diabetic telehealth clinic.

Dr. Karol Watson:

They offer discussion of future initiatives as well, that can help other communities in Canada. Such as, there's an initiative addressing hypertension in the Chinese population in Canada.

Dr. Karol Watson:

So this thoughtful paper, really looks at disparities in unique populations in Canada. More importantly, it offers potential roadmaps for other populations, solutions to address longstanding legacies of racism and colonialism.

Dr. Mercedes Carnethon:

Thank you so much, Karol, for that description from our neighbors from the north.

Dr. Mercedes Carnethon:

My second paper is really relevant during this hot month of July, in much of the United States and the upper hemisphere. And that's because Sameed Khatana and colleagues from the University of Pennsylvania, discuss how extreme heat is associated with higher cardiovascular mortality. For those of us who welcome the heat of summer and the opportunity to get out from behind our desks and exposed to some vitamin D, Khatana and colleagues reviewed county level daily data on temperature, and linked those data with mortality rates.

Dr. Mercedes Carnethon:

But before I summarize the findings, I invite you to California based cardiologists to join me in Chicago, where extreme heat is really only a problem for about 30 days a year. The authors found that between 2008 and 2017, when the heat index was above 90 degrees Fahrenheit, or 32.2 degrees Celsius, there was a significantly higher monthly cardiovascular mortality rate. In total, extreme heat was associated with nearly 6,000 additional deaths from cardiovascular disease. And sadly, black adults, older adults, and men, bore the greatest burden of mortality rates from extreme heat. So, we can all take lessons from that.

Dr. Mercedes Carnethon:

But turning to you now, Fatima.

Dr. Fatima Rodriguez:

Thanks so much, Merci. I'm from Florida, so I can definitely relate to the issues of extreme heat, but I'm very happy for the perfect year round weather here in Northern California.

Dr. Fatima Rodriguez:

My third paper is led by Dr. Zubair (and Chikwe) and colleagues from Cedar Sinai, and it describes changes in outcomes by race, in children listed for heart transplantation in the United States. I won't give all the details, but this research letter really nicely summarizes how the 2016 Pediatric Heart Allocation Policy revisions may have inadvertently widened health disparities between white and non-white children. This article touches on the difference between equality and equity, even in the most well-intentioned national policies. And I invite our listeners to read the full details in this special Circulation edition.

Dr. Mercedes Carnethon:

Thanks Fatima. Karol.

Dr. Karol Watson:

The next paper I'd like to discuss, is a community based cluster randomized pilot trial, of a cardiovascular mobile health intervention, preliminary findings of the FAITH! Trial, from LaPrincess Brewer and colleagues from the Mayo Clinic.

Dr. Karol Watson:

So it's well known that African Americans have suboptimal cardiovascular health metrics, such as less regular physical activity, suboptimal blood pressure levels, suboptimal diets. So the authors of this study hypothesize, that developing a mobile health intervention, in partnership with trusted institutions, such as, African American churches, might be an effective means to promote cardiovascular health in African American patients. So using a community based participatory research approach, they develop the FAITH! trial. FAITH stands for Fostering African American Improvement in Total Cardiovascular Health. The manuscript in this issue reports, feasibility and preliminary efficacy findings from this refined community informed mobile health intervention, using the FAITH! App, developed by the investigators.

Dr. Karol Watson:

They performed a cluster randomized control trial. Participants from 16 different churches in the Rochester, Minnesota and Minneapolis St. Paul, Minnesota areas. The clusters were randomized to receive the FAITH! App, that was the intervention group, or were assigned to a delayed intervention program. The 10 week intervention feature culturally relative and sensitive information modules, focused on American Heart Association's Life's Simple 7. Primary outcomes were changes in the mean Life Simple 7 score, from baseline to six months post intervention. They enrolled 85 participants, mean age was 52, and about 71% were female.

Dr. Karol Watson:

At baseline, the mean Life Simple 7 score was 6.8, and 44% of the individuals were characterized as being in poor cardiovascular health. The mean Life Simple 7 score of the intervention group, after the end of the intervention, increased by 1.9 points. In the control comparator group, it only increased by 0.7 point. Highly statistically significant, with P value of less than 0.0001 at six months.

Dr. Karol Watson:

Now this FAITH! Trial demonstrated preliminary findings, that suggest that a culturally sensitive and mobile health lifestyle intervention could be efficacious, promoting ideal cardiovascular health among African Americans. I think what's so important about this is that, they partnered with a very trusted group, the churches, and getting buy-in to a community that has had many reasons not to trust in the past, I think is critically important.

Dr. Mercedes Carnethon:

Well, thank you so much, Karol. My third paper is an original research investigation by Anoop Shah and colleagues from the University of Edinburgh, arguing that socioeconomic deprivation is an unrecognized risk factor for cardiovascular disease.

Dr. Mercedes Carnethon:

In their study, the authors evaluated how risk scores, with and without indicators of socioeconomic deprivation, performed in a population study in Scotland, the Generation Scotland: the Scottish Family Health Study, of over 15,000 adults. Again, I won't give away all the details, so that I keep our listeners excited to read the article, but all risk scores aren't created equally. And the observed versus expected number of events varied, based on whether the risk score included socioeconomic indicators or not. Further, the performance of the risk scores varied, based on the degree of deprivation that participants were currently experiencing. It's a thought provoking piece, that may challenge us to reconsider how we identify risks for cardiovascular disease in the population.

Dr. Mercedes Carnethon:

And I'm turning to you now, Fatima.

Dr. Fatima Rodriguez:

Sure thing, Merci. My last paper is led by Dr. Anna Krawisz, and is looking at how differences in comorbidities explain racial disparities in peripheral vascular interventions. This study used Medicare fee for service data from 2016 to 2018, to examine risks of death and major amputation, one year following peripheral endovascular intervention. They found that, black Medicare beneficiaries had higher population level need for peripheral endovascular interventions, and that black race was associated with adverse events following these interventions. However, after adjusting for the higher prevalence of comorbidity, such as diabetes, hypertension, and chronic kidney disease in black populations, this observation was eliminated. Again, like a common theme in many of the articles we've discussed today, this is to suggest, that moving upstream to reduce risk factors is really critical to eliminate disparities in cardiovascular disease outcomes. And this includes the understudy disease of peripheral arterial disease. Black adults were also less likely to be treated with guideline directed medical therapies in this study.

Dr. Mercedes Carnethon:

Well, thank you so much, Karol and Fatima, for your wonderful summaries of all of the excellent pieces in this issue.

Dr. Karol Watson:

And I'd like to thank all of the fantastic investigators who submitted their really fantastic work, so that we could produce this issue. And really, keep them coming. We thank you for this.

Dr. Mercedes Carnethon:

Well, thank you. So now we'll transition to our feature discussion with Drs. Wadhera and Kyalwazi, from Beth Israel Deaconess Medical Center, and the Harvard Medical School.

Dr. Mercedes Carnethon:

Welcome to this episode of Circulation on the Run podcast. I'm really pleased to host this feature discussion. My name is Mercedes Carnethon, from the Northwestern University Feinberg School of Medicine. And I'm pleased to have with us today, Drs. Ashley Kyalwazi and Rishi Wadhera from Beth Israel Deaconess, and the Harvard Medical School. And they shared with us a really important piece of work for our disparities issue, that is describing disparities in cardiovascular mortality, between black and white adults in the United States from 1999 to 2019. First of all, I really want to thank you both for submitting your important work to circulation.

Dr. Rishi Wadhera:

Thanks so much Mercedes, and thanks for the opportunity to submit and revise our manuscript.

Ms. Ashley Kyalwazi:

Thanks so much for having us.

Dr. Mercedes Carnethon:

Wonderful. I'd like to start out with you Rishi. Tell our listeners about the objectives of your study, and what your motivation was for carrying out this work.

Dr. Rishi Wadhera:

Well, I think it's been well established that, black adults are disproportionately impacted by cardiovascular disease, and experience worse cardiovascular outcomes, due to systemic inequities and structural racism. And so, the goal of our study was really, to perform a comprehensive national evaluation of how age adjusted cardiovascular mortality rates have changed for black adults, compared with white adults, over the past two decades in the United States, with a focus on some key subgroups, like younger adults and women.

Dr. Rishi Wadhera:

In addition, because we know that the neighborhood community or environment in which you live in the US, has an immense influence on cardiovascular health, we also examine changes in cardiovascular mortality for black and white adults by geographic region, rurality, and neighborhood racial segregation. And our primary objective was really, to understand whether disparities in cardiovascular outcomes between black and white adults improved, worsened, or didn't change, from 1999 to 2019.

Dr. Rishi Wadhera:

And there are some reasons to think we might have made progress in narrowing the mortality gap between these groups over this time period. There have been substantial improvements in preventative care and treatments for cardiovascular disease over the past two decades. And the expansion of insurance coverage under the Affordable Care Act, led to increases in access to care, cardiovascular risk factor screening and treatment, particularly, for black adults. At the same time, we know that, black adults were disproportionately affected by the economic recession of 2008, and experienced worsening poverty, job loss, and wealth loss, all of which are inextricably tied to cardiovascular health, and more broadly, health. And so that was our interest in really exploring how disparities in cardiovascular mortality have changed amongst black and white adults between 1999 and 2019.

Dr. Mercedes Carnethon:

Thank you so much for that summary. It's really nice to have these sort of pieces that really outline for us a lot of data, and across a number of different domains. Because it allows us really, a chance to think about those data, and how we can use those data in order to help improve health.

Dr. Mercedes Carnethon:

So tell me a little bit, Ashley, about what your study found.

Ms. Ashley Kyalwazi:

Absolutely. Yeah. So in the United States, overall, we found that age adjusted cardiovascular mortality rates declined for both populations, so both black and white adults, by around 40% from 1999 to 2019. So encouraging declines across the country. We found that these patterns were similar for both women and men, when we stratified by gender, over the 20 year period. While mortality rates declined in all regions, we still did find disparities when we stratified by age. So between the younger and older black women, versus younger and older black men, we found that, younger black men and black women were dying at higher rates, and were at increased risk of death from cardiovascular mortality, compared to younger white women and men, respectively. But we also found that black women and men living in rural areas consistently experienced highest mortality rates. And then finally, black adults living in higher areas of residential racial segregation, and compared to those living in low to moderate areas of residential racial segregation had higher mortality rates, as well.

Dr. Mercedes Carnethon:

Wow, this is a lot. And it's really describing a lot of disparities across multiple domains that we can easily measure. Which aspects of these results in your work did you find the most surprising, Ashley?

Ms. Ashley Kyalwazi:

Yeah, I was intrigued, I think overall, by just the gaps. I was very encouraged by, I think, the declines over time. On an absolute scale, the country has made a lot of progress, in terms of reducing cardiovascular mortality rates for both groups. But still, by the end of the study period, there were notable gaps between black adults and white adults. Particularly, between black, younger women and white, younger women, we see that by the end of the study period, black, younger women still remain over two times the risk of death from cardiovascular disease than younger white women. Which I think, leaves something to be desired from a public health and health policy standpoint, with regards to how we're going to kind of decrease these disparities.

Dr. Mercedes Carnethon:

I wanted to follow up on that point. Why do you think you see such disparities between black and white younger women? I love the opportunity of the podcast to allow authors a chance to speculate, beyond what they would do in the paper.

Ms. Ashley Kyalwazi:

Absolutely. I think that, there are a lot of great efforts on a national scale right now, to kind of address the disparities between black and white women. The Association of Black Cardiologists, for example, had a whole paper out about ways to really target and provide preventative measures for black women. So for example, working with communities, where there's a high proportion of black women, to figure out what community based research looks like. Engaging with churches, different types of methods, to really understand the barriers that black women face towards obtaining preventative care.

Ms. Ashley Kyalwazi:

I think the disparities that we are seeing, could potentially parallel well known and documented disparities in maternal health outcomes. So I think, from a perspective of preventative care, really thinking about, what are the barriers to healthy cardiovascular profiles for black women pre and postnatally, to ensure that their cardiovascular health is an actionable before and after the pregnancy?

Ms. Ashley Kyalwazi:

And then I think, broadly, the challenges that black women face, mirror the challenges of black adults, plus the additions of like social stressors, things that we looked at in this study neighborhood residential racial segregation, access to healthcare, and all of those things kind of contribute to the profile that black women face, in terms of being often, the heads of their households as well, and carrying on a lot of different societal challenges.

Dr. Mercedes Carnethon:

Thank you so much for that. I really appreciate that.

Dr. Mercedes Carnethon:

As I read the paper, one of the findings that I found the most surprising, and it was challenging for me to understand, is that while the absolute difference in rates was declining, or getting smaller over time, between black and white men and women, the rate ratios remained elevated across the course of time. I think, these concepts can be a little challenging to understand, not just to me, but to others as well. That when one measure of effect is showing progress, but another is still reporting a disparity.

Dr. Mercedes Carnethon:

Rishi, could you explain for our listeners, how we can see progress on one metric, but still find a mortality rate ratio that's 1.3 times higher in black, as compared with white men, for example?

Dr. Rishi Wadhera:

Thanks for that really important question, Mercedes. Just to summarize, we presented two outcomes that compared cardiovascular deaths among black and white adults in our paper, absolute rate differences, and then separately, rate ratios. And I think, both measures provide important complementary insights. I think that, understanding the absolute rate difference in cardiovascular deaths is critically important from a public health perspective, because it characterizes excess deaths experienced by black adults, compared with white adults. The fact that the absolute rate difference in cardiovascular death has narrowed over the past two decades between these groups is positive news. In contrast, the rate ratio provides us with important insights on the relative difference, or disparity or gap, between black and white adults.

Dr. Rishi Wadhera:

So again, both are important, both provide sort of synergistic and complimentary insights. And just to sort of cement that, as an example, you were talking to Ashley earlier, about some of the patterns we noticed amongst younger black women and white women. The absolute rate difference in cardiovascular deaths between younger black women, compared to younger white women, decrease from 91 per 100,000 in 1999, to about 56 per 100,000 in 2019. And that's good progress. However, our rate ratio analysis indicated that, still in 2019, young black women were 2.3 times more likely to die of cardiovascular causes than young white women. Highlighting that, we still have a lot of work to do, to address disparities between these groups. Some of which, Ashley already talked about.

Dr. Mercedes Carnethon:

Thank you so much for that excellent explanation. I know it's certainly, I find it alarming to hear, but then I remember I'm actually not young anymore. So maybe this doesn't apply to me quite as much. But no, I appreciate the explanation.

Dr. Mercedes Carnethon:

So your report was really unique, in that you studied these disparities, as we discussed, across a number of domains, age, geography, even racial residential segregation. Whereas, the pronounced disparities have been reported in a few of the other domains that you studied. I'm really interested in hearing more about racial residential segregation. I think, a lot of people don't fully understand what the concept is, and the ways in which racial residential segregation may contribute to higher rates of cardiovascular death among blacks.

Dr. Mercedes Carnethon:

Ashley, would you mind explaining to us first, what racial residential segregation is? And then really, how it would contribute to higher rates of cardiovascular death?

Ms. Ashley Kyalwazi:

Yeah, absolutely. So in its simplest terms, racial residential segregation is just the physical separation of two or more groups by race and/or ethnicity into different neighborhoods. What gets tricky is, like the long history within the United States of how we got to this point, where you see numerous degrees of segregation across the country. Residential racial segregation in the United States dates back to policies pre World War II, that resulted in kind of discriminatory banking practices and policies. For example, reverse red lining and gentrification, much of which the extent still exists today. And that's what we see kind of, I think, in our results when we looked at high versus low to moderate areas of residential racial segregation, and how those kind of track onto the trends that we see in cardiovascular mortality over time.

Ms. Ashley Kyalwazi:

The residential racial segregation impacts almost every aspect of life. You can imagine where you live, we know definitely impact, for example, your zip code can impact health outcomes. We've seen individual's cardiovascular health kind of trend with something as simple as your zip code. Where you live really does impact your, for example, access to affordable housing, health insurance, where your primary care physician is, whether or not you even have one. What that trip looks like to see your primary care physician, is it hours on end, and unrealistic to get to, or is it just around the corner?

Ms. Ashley Kyalwazi:

Educational opportunities, which leads to income, which we know is linked to cardiovascular disease employment in all of these aspects. Even access to green space. In some metropolitan areas that are more segregated, we see that, black adults, for example, have less access to green space, and numerous studies have shown that, that does impact overall health, but then also, from a cardiovascular disease perspective as well. So I think that, given that we know that lack of access to all of these key determinants can adversely affect cardiovascular mortality, and just general cardiovascular health, I think is very interesting that we found that, there was this link between high residential racial segregation and cardiovascular mortality. That we definitely can look into more, and understand kind of in more detail, that the mechanisms at play and ways to intervene.

Dr. Rishi Wadhera:

And just to layer onto and reinforce Ashley's really excellent answer to that question. We know that black adults are more likely to live in disadvantaged neighborhoods, because of the intentionally racist policies that were put in place many decades ago, that Ashley described so well. And black communities and segregated communities, as Ashley mentioned, are less likely to have access to primary care, high quality hospital care, and green spaces, but also, pharmacies and healthy foods. And we also know, there's a lot of empirical work that's shown that black communities, disproportionately experience psychosocial stressors, trauma.

Dr. Rishi Wadhera:

Also, these communities are disproportionately exposed to climate change, such as extreme heat. There was a recent paper that extreme heat has been linked to increases in cardiovascular mortality, and disproportionately affects black communities. These communities are also disproportionately exposed to pollution. All of these things we know are linked to cardiovascular health, and represent the effects of again, intentionally racist policies that were put into place many decades ago, the effects of which still persists today. Which will require equally intentional policies that aim to dismantle these longstanding effects, if we hope to make progress in advancing health equity, and specifically, cardiovascular health equity.

Dr. Mercedes Carnethon:

I appreciate the facility with which the two of you address the multiple complex contributors to cardiovascular health. It's even more impressive coming from two clinicians. So I really appreciate you taking the time to explain this. And this is where I really like the opportunity to open up and say, what more do you want your clinical peers to know about? For example, how does this affect the day to day encounters that you have in clinic with black patients, and other patients who've been traditionally underrepresented? How do you hope your clinical peers will use this information to promote cardiovascular health equity? And I'll open it up to either of you to respond.

Ms. Ashley Kyalwazi:

Yeah, I can get on that one. I think that, the disparities that our paper highlights, really requires a multisystem level approach to tackling, from public health to public policy. But I think at a provider level, to your question, Mercedes, physicians must be able to, I think at first, read the data and understand that these disparities exist.

Ms. Ashley Kyalwazi:

If there's no insight with regards to the risk profiles, that simply black women and black men have, because of systemic racism, because of these inequities, then I think, we're already kind of steps behind where we need to be. So recognizing disparities in cardiovascular disease burden for black men and women, prioritizing education on cardiovascular risk. A lot of the conditions are preventable with appropriate access to care and education around these topics. And so, providing education about the signs and symptoms of heart disease and treatment options for black men and women. Recognizing the history of medical mistreatment for black adults in this country. And really, tailoring the approach towards the individual who comes into the office, who might have very valid reasons for hesitating to take a medication, or a lot of questions that need time and consideration.

Ms. Ashley Kyalwazi:

At a research level, I think, more data and resources should be spent on studying risk prevention and treatment for cardiovascular disease in black adults, and really, developing more community based models, that really get at the specific interventions that work within black communities, that are culturally specific, that are targeted and relevant, for the populations that we're talking about.

Ms. Ashley Kyalwazi:

I think finally, and I'll let Rishi chime in, I think, this is shockingly low level of racial and ethnic representation in the field of cardiology as a whole. And we know that, diversity in healthcare can improve health outcomes. So from a cardiology perspective, I think, training the next generation of black young men and women to take up their seats at the table, and really advocate for some of these issues, alongside individuals who are already doing great work, would be essential towards reducing disparities that we see. And so all of the above, I think, I would encourage for my colleagues.

Dr. Mercedes Carnethon:

Thank you so much. Rishi, any final thoughts?

Dr. Rishi Wadhera:

No, I'll just add onto Ashley's again, really outstanding response that, this is a tension we face when we see patients in cardiology clinic all the time. I think, awareness about disparities, and the multiple factors that contribute to disparities in cardiovascular health, particularly, as it relates to race and ethnicity, are increasingly being recognized as they should be.

Dr. Rishi Wadhera:

And one of the challenges, how much can clinicians do within the bounds of hospital walls? We can make sure that we get patients the treatments they need. We can make sure we screen patients appropriately. But we know, as we've discussed, that so many factors beyond hospital walls, like widening income inequality, that's disproportionately affected black adults, and has been worsening over the last several decades. Widening educational inequality, that again, disproportionately affects black adults, and has been worsening over decades, also affect how. So I think, thinking about how clinicians, researchers, and policy makers, can work together to address some of these challenges, issues, and broader social determinants of health, that also exist outside our clinical practice, or hospital walls, will be really, really important, if we are serious about advancing health equity in this country.

Dr. Rishi Wadhera:

I don't think, we can operate in silos anymore. In the clinical world, in the research world, in the policy making world, we need more researchers and clinicians to have a seat at the table when it comes to policy making, individuals who understand how all of these complex factors are inextricably tied to one another, so that we can seek and implement solutions that advance cardiovascular health.

Dr. Mercedes Carnethon:

Thank you so much. The insights that we've gotten, from not only your written work, but even more importantly, this opportunity to speak with you today, and share with our readership, have just been invaluable. And I really appreciate the amount of time that you spent, in preparing the manuscript, and really contextualizing the findings with us today, as well as in writing. So thank you so much for contributing this really important work to our annual disparities issue.

Dr. Rishi Wadhera:

Thank you so much, Mercedes. We really appreciate all the time you and the Circulation team took to make the manuscript stronger.

Ms. Ashley Kyalwazi:

Thank you so much for having us. It was truly an honor to have this conversation and to submit our work.

Dr. Mercedes Carnethon:

Well, thank you.

Dr. Mercedes Carnethon:

That wraps up our feature discussion for this episode of Circulation on the Run podcast. I'm Mercedes Carnethon, from Northwestern University, Associate Editor and guest editor of the disparities issues. So thank you so much.

Dr. Greg Hundley:

This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors, or of the American Heart Association. For more, please visit hajournals.org.