Heart Disease Risk: Bridging Racial And Ethnic Gaps

In the US, heart disease is the leading cause of death in adults.¹ However, disparities exist in the incidence and mortality of heart disease, with minority races being more affected. Developing strategies to reduce these differences and improve health equity is essential. 

Introduction to cardiovascular disease risks for minorities

Cardiovascular disease refers to disorders involving the heart and blood vessels, such as coronary heart disease, heart attacks, heart failure, and stroke. 

It significantly affects quality of life and life expectancy, causing almost 700,000 deaths in the United States annually.²

Cardiovascular disease incidence differs by race. In 2019, cardiovascular disease affected:³

• 5.5% of White people

• 5.9% of Black people

• 3.2% of Asian people

• 5.4% of Hispanic people

Differences are also found in mortality. Black people are twice as likely to die from heart disease than White people.⁴

Research suggests that access to cardiovascular disease diagnostic tools and treatment differs between White people and people of color.⁵ It also showed Black people have higher rates of early hospitalization and death than White people. 

Modifiable risk factors of cardiovascular disease

Anyone can get cardiovascular disease. However, certain factors increase the risk of developing it. 

Some risk factors can be managed on a personal level:

High blood pressure

High blood pressure is when the blood exerts too much force on the walls of the blood vessels. This damages the lining of the vessels, reducing the flow of oxygen and blood to the heart and significantly increasing the risk of heart disease.⁶

Among races in the United States, Black adults are most likely to have high blood pressure, as well as have it earlier and with increased severity.⁷ Although this is mainly due to social determinants of health, there’s evidence that genetics may also be at play.⁸ ⁹

Poor dietary habits

Diet is closely linked to heart health.

Too much sodium can cause high blood pressure, which increases the risk of heart disease.¹⁰

A diet high in saturated and trans fats can lead to atherosclerosis.¹¹ This is when plaque builds up in the arteries, thickening and hardening them. The build-up makes it harder for blood to flow through and increases the risk of heart disease. Furthermore, these atherosclerotic plaques can rupture and block blood flow, leading to events such as a heart attack.

Obesity

Excess body fat is associated with other cardiovascular disease risk factors, such as diabetes, high blood pressure, and high cholesterol.¹²

Hispanic and Black adults are more likely than people of other races to have obesity.¹³

High cholesterol

When there’s too much cholesterol in the blood, it builds up in the blood vessels' walls, contributing to plaque formation and increasing the risk of heart attacks and other conditions.¹⁴

Lack of physical activity

Not getting enough physical activity is strongly associated with cardiovascular disease.¹⁵

Smoking and secondhand smoke exposure

People who smoke are twice as likely to get cardiovascular disease than non-smokers. Former smokers are still at risk, although stopping smoking is beneficial.¹⁶

People exposed to secondhand smoke are also more likely to develop cardiovascular disease.¹⁷

Type 2 diabetes

Type 2 diabetes is hallmarked by an insufficient response to insulin and increased sugar levels in the blood.¹⁸ The excess sugar can damage blood vessels in the long term, making it harder for blood to flow. 

American Indian/Native Alaskan, Hispanic, and Black adults are more likely than people of other races to have diabetes.¹⁹

Non-modifiable risk factors of cardiovascular disease

Some risk factors can’t be managed or controlled.

Age

The risk of cardiovascular disease increases from age 35.²⁰

Sex

Men are more likely than women to get heart disease.²¹

Genetics

People with a family history of premature heart disease, such as a sibling or parent, are more likely to develop heart disease.²² This may be because certain genetic markers increase the risk of cardiovascular disease. Family members may also share common environmental factors that predispose them to cardiovascular disease.²³

Factors contributing to the racial disparity in cardiovascular disease

People of color experience worse social and environmental conditions than White people in the United States, including in their access to healthcare.²⁴ Much of this stems from structural racism. 

Socioeconomic factors

Socioeconomic status is one of the largest cardiovascular disease risk factors.²⁵

Social determinants of health are the economic, environmental, and social conditions that influence health and health outcomes, such as cardiovascular disease. These include poverty and economic instability, employment, physical living conditions in the home and neighborhood, education, and access to adequate healthcare.²⁶

Poverty/economic instability

Differences in income, wealth, employment status, and job stressors are linked to racial disparities in cardiovascular health, modifiable risk factors of cardiovascular disease, and access to healthcare.²⁷

People of color tend to have lower incomes and experience more barriers to employment.²⁸

Living in an unhealthy physical environment/neighborhood

Living in an unhealthy physical environment increases the risk of cardiovascular disease and leads to worse outcomes.²⁹ High-poverty neighborhoods may have greater exposure to air pollutants, fewer healthcare facilities, fewer affordable healthy food options, and fewer safe spaces to walk and exercise in. 

Black, American Indian/Native Alaskan, and Hispanic people are more likely to live in high-poverty neighborhoods.³⁰ Historical racist and discriminatory policies have prevented these minority groups from owning houses in highly resourced and safe areas. 

Lack of adequate education/health education

Due to historical racism in education, people of color face barriers to quality education. Black children are more likely to attend high-poverty schools, drop out, and not attend college.³¹

A lack of education may increase the risk of cardiovascular disease by increasing the likelihood of living in poverty, facing food insecurity, and participating in other unhealthy lifestyle behaviors.³² Furthermore, people with lower overall education may have lower health literacy and less understanding of cardiovascular disease than higher educated people. 

Health system disparities

Even after controlling for socioeconomic and clinical variables, research shows that racial disparities in the health system persist.³³

Intentional or unintentional bias

Some healthcare providers demonstrate intentional or unintentional racial discrimination. They may show bias through patient interactions, treatment decisions, adherence, and outcomes.

A systematic review of 15 studies revealed a statistically significant overall implicit bias effect, with healthcare providers showing a preference for White patients over people of color. The study also highlighted instances where healthcare providers are more likely to offer treatments such as transplants to White patients due to bias regarding trust and expectations of patient adherence to necessary lifestyle changes.³⁴

Access to quality healthcare

Differences in access to quality healthcare also create racial disparities in cardiovascular disease. 

For example, Black patients are 24% less likely to receive coronary artery bypass grafting treatment at top hospitals than White patients from the same socioeconomic background.³⁵ Black patients are also less likely than White patients to receive fibrinolytic (blood clot busting) medication after a heart attack.³⁶

Lack of quality care has also meant that hospitals that provide care to underserved communities typically have higher readmission and mortality rates from cardiovascular disease than hospitals that cater more to White communities.³⁷

It’s also important to consider insurance. For example, a lack of insurance can make it difficult to access healthcare. Compared to White individuals, Black and Hispanic people are respectively two and four times more likely not to have health insurance.³⁸

Black people are also less likely to have private health insurance. This means they may not be able to select preferential hospitals that could provide them with the best care.³⁹ Research has also found differences in health outcomes between patients relying on Medicaid compared to those who are privately insured. For example, one study found that patients using Medicaid had a higher likelihood of hospital readmission and death from a heart attack compared to patients with private insurance.⁴⁰

How to improve racial/ethnic disparities in cardiovascular disease risk and outcome

With modern heart disease treatments available, issues must be addressed to allow minorities to access them readily. 

Improving access to insurance and medication coverage

Providing greater health insurance coverage to minority groups is important in reducing disparities in cardiovascular care.⁴¹

Another important step is increasing medication coverage, including improving medication adherence.⁴²

Improving the use and access of clinical data platforms

From a research point of view, collecting and integrating data relating to race/ethnicity and social determinants of health into clinical platforms must be improved to be easily used and accessed.⁴³

Cultural competence training

Healthcare providers should undergo training in cultural competence and historical racial disparities in healthcare to increase their understanding and reduce implicit bias and discrimination.⁴⁴

Create frameworks that model cardiovascular disease risk

Frameworks can help us understand the interactions between race, social determinants of health, and cardiovascular disease. They can help us assess the risk of cardiovascular disease in racial minority groups.⁴⁵

Anti-discrimination laws

On a wider scale, Federal and local anti-discrimination laws concerning healthcare providers could be implemented.⁴⁶

Programs that reduce disparities

Two programs have been created with the goal of reducing racial/ethnic disparities in cardiovascular disease:

Million Hearts

Million Hearts is an initiative to prevent one million heart attacks and strokes in the next five years by implementing small, evidence-based priorities and targets to improve cardiovascular health.⁴⁷

The overall goal of Million Hearts is to increase health equity, including among minority groups.⁴⁸ One of their interventions involves delivering medication therapy management, self-measured blood pressure monitoring, and other blood pressure management tools in trusted non-healthcare spaces, such as barbershops, salons, and churches. Million Hearts also supports policies prohibiting the sale of flavored tobacco products. 

REACH

The Racial and Ethnic Approaches to Community Health (REACH) program focuses on reducing racial and ethnic disparities in health by carrying out community-based, culturally appropriate programs for minority races and ethnic groups.⁴⁹ Some examples include enhancing access to nutritious food and connecting people to community programs to help them manage heart disease.

REACH’s goal is to promote healthy behaviors and reduce chronic disease risk factors.⁵⁰

Ways to reduce the risks and development of cardiovascular disease

Control blood sugar

Controlling blood sugar is important because uncontrolled diabetes increases the risk of cardiovascular disease. Lifestyle changes such as dietary modifications, exercise, and weight management can help control blood sugar.⁵¹

Eat well

A diet high in fruits, vegetables, oily fish, whole grains, legumes, non-fat dairy, fiber, and polyunsaturated fats can reduce the risk of cardiovascular disease.⁵²

Red and processed meat, refined grains, sugar-sweetened beverages, saturated and trans fats, and sodium should be limited as these can increase the risk of heart disease.⁵³

Reduce alcohol

People who drink alcohol should try to do so in moderation.⁵⁴

Get active

It’s recommended to get 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity muscle- and strength-building exercise each week.⁵⁵ However, any exercise is better than none, and even small increases in physical activity can reduce the risk of cardiovascular disease.⁵⁶

Maintain a healthy body mass

People who are overweight or living with obesity are recommended to reach a healthy weight.⁵⁷ Losing 5% of body weight can have health benefits.⁵⁸

Develop a smoking quit plan

People who smoke are advised to stop smoking to reduce the risk of cardiovascular disease.⁵⁹

The lowdown

Racial discrimination is clearly associated with heart disease incidence and mortality. Moving forward, researchers, medical professionals, and everyone involved in managing the health system in the United States must work to reduce these gaps. Increasing access to diagnostic processes and high-quality, timely, personalized treatment interventions designed for minority races and ethnic groups could help improve equity.

FAQs

Is heart disease genetic?

Inheriting certain genes can increase the risk of heart disease, but lifestyle and environmental factors play the most prominent role in developing the condition.  

Can you get heart disease in your 20s?

Heart disease is more common in older people. However, people in their 20s can get heart disease. 

What race has the highest rate of diabetes?

American Indian/Alaskan Native populations, followed by Hispanic and Black people, have the highest rates of diabetes.⁶⁰ In total, 14.5% of American Indian/Alaskan Native and 12% of Black people develop diabetes in the United States.⁶¹