Atherosclerotic Cardiovascular Risk for African Americans
DECEMBER 19, 2018
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA
Keith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA: If you look at all the factors related to heart failure readmission, black race, along with age, chronic kidney disease, and socioeconomic factors, they clearly mean that these patients are at increased risk for readmission. Addressing these patients early in the hospital process with team care is essential, along with the follow-up within 7 to 10 days to curtail unnecessary readmissions for heart failure.
In terms of cardiovascular health, therefore, if you look across all of the different conditions that I’ve discussed, it was estimated by the American Heart Association that as many as 2 million African Americans have died unnecessarily over the last decade due to disparities in cardiovascular care.
Now let’s look at the ASCVD [atherosclerotic cardiovascular disease] risk calculator. Most of you have noted that along with the person’s age, their gender, the presence of hypertension, diabetes, and cholesterol levels, there is an increased risk for African American status. Again, I don’t think this is driven by biology, but the observational data that I’ve described previously suggest that African Americans have an increased risk of cardiovascular disease. And the ASCVD risk calculator from the American College of Cardiology/American Heart Association brings attention to the increased risk related to African American status.
Even in persons who have familial hypercholesterolemia [FH] where you have a marked increase in LDL [low-density lipoprotein] cholesterol of 190 or above, some of the latest data from the CASCADE FH Registry suggest that African Americans and Asians have less diagnosis of FH and, even when FH is present, less appropriate use of statins. PCSK9 inhibitors are of course costly, but in many of these patients, they can be lifesaving. As a society, we need to do everything we can to make sure that people have access to appropriate lifesaving evidence-based medications, regardless of race, ethnicity, or social class.
When observing some of the conditions that people live in, we know that exercise, access to healthy foods—such that a person can mimic a DASH [dietary approaches to stop hypertension]-like diet—and relief of stress are all related to a person’s status in cardiovascular health.
Overall, therefore, we now have what we call in New Orleans a gumbo, a mixture of factors that leads to these unnecessary, costly, and deadly disparities. Even in cardiology care when we know, for instance, PCIs [percutaneous coronary interventions] for acute myocardial infarction, for STEMIs [ST-elevation myocardial infarction], and the use of ICDs [implantable cardioverter-defibrillator] in patients who have chronic heart failure with decreased ejection fraction, we still see these disparities in the application of care. Therefore, it’s not just risk factors but real evidence-based approaches to care that seem to be disparate.
One recent study suggested that those persons who have primary care given by a cardiologist in intensive care with heart failure had better outcomes but that African Americans have less care by the cardiologists. This suggests that there are things that we as providers can do to make sure that we are appropriately applying evidence-based medicines, including devices and interventions across all populations.
What can we do going forward as providers? The Los Angeles Barbershop [Blood Pressure] Study gave us some idea that perhaps we can do more to control hypertension. They actually looked at barbershops as hypertension controlled centers. Having a clinical pharmacist with direct care in the barbershop led to a decrease in blood pressure such that 63% of the patients starting with a systolic blood pressure of approximately 154 were able to control their blood pressures to a systolic less than 130.
Some of the essential components of the barbershop study were not only having a comfortable source of care—and of course we don’t all need to be barbers—but also making sure that our clinic environments are a comfortable source of care but also have a team concept. In the barbershop study, it was the clinical pharmacist. In our own practice, it may be the nurse practitioner or the physician assistant, along with the appropriate use of medications. They use the long-acting RAS [renin-angiotensin system] blocking agent along with the long-acting calcium channel blocker and a more powerful thiazide-type diuretic, indapamide, which is similar to chlorthalidone to control blood pressures in that setting.
Regarding access to care, fortunately, several nonprofits are now starting to band together, including the Association of Black Cardiologists and others, to try to help providers get access to care for some of the newer medicines. We now have data that direct oral anticoagulants and PCSK9 inhibitors are not equally used across our populations. And these various nonprofits are giving us tools on how we can better get prior authorization completed to get these medications.
Overall, if you look at some of the things that providers can do, that includes not only applying evidence-based devices and interventions but also making sure that newer medicines are available to all patients—again, regardless of race, ethnicity, or social class.
Transcript edited for clarity.