Addressing Structural Racism Through Public Policy Advocacy: A Policy Statement From the American Heart Association.

During the COVID-19 pandemic, the American Heart Association created a new 2024 Impact Goal with health equity at its core, in recognition of the increasing health disparities in our country and the overwhelming evidence of the damaging effect of structural racism on cardiovascular and stroke health. Concurrent with the announcement of the new Impact Goal was the release of an American Heart Association presidential advisory on structural racism, recognizing racism as a fundamental driver of health disparities and directing the American Heart Association to advance antiracist strategies regarding science, business operations, leadership, quality improvement, and advocacy. This policy statement builds on the call to action put forth in our presidential advisory, discussing specific opportunities to leverage public policy in promoting overall well-being and rectifying those long-standing structural barriers that impede the progress that we need and seek for the health of all communities. Although this policy statement discusses difficult aspects of our past, it is meant to provide a forward-looking blueprint that can be embraced by a broad spectrum of stakeholders who share the association's commitment to addressing structural racism and realizing true health equity.

Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association.

Cardiovascular disease is the leading cause of death in women, yet differences exist among certain racial and ethnic groups. Aside from traditional risk factors, behavioral and environmental factors and social determinants of health affect cardiovascular health and risk in women. Language barriers, discrimination, acculturation, and health care access disproportionately affect women of underrepresented races and ethnicities. These factors result in a higher prevalence of cardiovascular disease and significant challenges in the diagnosis and treatment of cardiovascular conditions. Culturally sensitive, peer-led community and health care professional education is a necessary step in the prevention of cardiovascular disease. Equitable access to evidence-based cardiovascular preventive health care should be available for all women regardless of race and ethnicity; however, these guidelines are not equally incorporated into clinical practice. This scientific statement reviews the current evidence on racial and ethnic differences in cardiovascular risk factors and current cardiovascular preventive therapies for women in the United States.

Research Goes Red: Early Experience With a Participant-Centric Registry.

RATIONALE: Cardiovascular disease remains the leading cause of death in women. To address its determinants including persisting cardiovascular risk factors amplified by sex and race inequities, novel personalized approaches are needed grounded in the engagement of participants in research and prevention. OBJECTIVE: To report on a participant-centric and personalized dynamic registry designed to address persistent gaps in understanding and managing cardiovascular disease in women. METHODS AND RESULTS: The American Heart Association and Verily launched the Research Goes Red registry (RGR) in 2019, as an online research platform available to consenting individuals over the age of 18 years in the United States. RGR aims to bring participants and researchers together to expand knowledge by collecting data and providing an open-source longitudinal dynamic registry for conducting research studies. As of July 2021, 15 350 individuals have engaged with RGR. Mean age of participants was 48.0 48.0±0.2 years with a majority identifying as female and either non-Hispanic White (75.7%) or Black (10.5%). In addition to 6 targeted health surveys, RGR has deployed 2 American Heart Association-sponsored prospective clinical studies based on participants' areas of interest. The first study focuses on perimenopausal weight gain, developed in response to a health concerns survey. The second study is designed to test the use of social media campaigns to increase awareness and participation in cardiovascular disease research among underrepresented millennial women. CONCLUSIONS: RGR is a novel online participant-centric platform that has successfully engaged women and provided critical data on women's heart health to guide research. Priorities for the growth of RGR are centered on increasing reach and diversity of participants, and engaging researchers to work within their communities to leverage the platform to address knowledge gaps and improve women's health.

Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women.

PURPOSE OF REVIEW: Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups. RECENT FINDINGS: There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

Heart Centers for Women: Historical Perspective on Formation and Future Strategies to Reduce Cardiovascular Disease.

Heart Centers for Women (HCW) developed as a response to the need for improved outcomes for women with cardiovascular disease (CVD). From 1984 until 2012, more women died of CVD every single year in comparison with men. Initially, there was limited awareness and sex-specific research regarding mortality or outcomes in women. HCW played an active role in addressing these disparities, provided focused care for women, and contributed to improvements in these gaps. In 2014 and 2015, death from CVD in women had declined below the level of death from CVD in comparison with men. Even though awareness of CVD in women has increased among the public and healthcare providers and both sex- and gender-specific research is currently required in all research trials, not all women have benefitted equally in mortality reduction. New strategies for HCW need to be developed to address these disparities and expand the current HCW model. The HCW care team needs to direct academic curricula on sex- and gender-specific research and care; expand to include other healthcare professionals and other subspecialties; provide new care models; address diversity; and include more male providers.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association.

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions.

Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Evolving, innovating, and revolutionary changes in cardiovascular imaging: We've only just begun!

In this review, we highlight the need for innovation and creativity to reinvent the field of nuclear cardiology. Revolutionary ideas brought forth today are needed to create greater value in patient care and highlight the need for more contemporary evidence supporting the use of nuclear cardiology practices. We put forth discussions on the need for disruptive innovation in imaging-guided care that places the imager as a central force in care coordination. Value-based nuclear cardiology is defined as care that is both efficient and effective. Novel testing strategies that defer testing in lower risk patients are examples of the kind of innovation needed in today's healthcare environment. A major focus of current research is the evolution of the importance of ischemia and the prognostic significance of non-obstructive atherosclerotic plaque and coronary microvascular dysfunction. Embracing novel paradigms, such as this, can aid in the development of optimal strategies for coronary disease management. We hope that our article will spurn the field toward greater innovation and focus on transformative imaging leading the way for new generations of novel cardiovascular care.

Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations.

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

Sex-Specific Disparities in Risk Factors for Coronary Heart Disease.

In the past two decades, focused research on women at risk for cardiovascular disease (CVD) has helped to clarify our understanding of some of the sex-specific factors that are important in the prevention and early detection of coronary atherosclerosis with a resultant 30 % decrease in the number of women dying from CVD. In spite of these advances, CVD, specifically, ischemic heart disease due to coronary atherosclerosis is the leading cause of cardiovascular death of women in the USA. The 2010 landmark Institute of Medicine (IOM) report, "Women's Health Research--Progress, Pitfalls and Promise," highlighted the fact that although major progress had been made in reducing cardiovascular mortality in women, there were disparities in disease burden among subgroups of women, particularly those women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment [1]. The IOM recommended targeted research on these subpopulations of women with the highest risk and burden of disease. Causes of disparities are multifactorial and are related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. In this article, we review a few of the contributing factors to the disparities in ischemic heart disease in women with a focus on the subgroups of women of Black, Latino, and South Asian descent who are at high risk for morbidity and mortality from CVD.

Causes of Death Among Health Care Professionals in the United States.

Specific causes of mortality among various types of health care professionals (HCPs), including those characterized by age, gender, and race, have not been well described. The National Occupational Mortality Surveillance data for deaths in 26 US states in 1999, 2003-2004, and 2007-2014 were queried to address this question. Proportionate mortality ratios (PMRs) were calculated to compare specific causes of mortality among HCPs compared with those among the general population. HCPs were less likely to die from heart disease (PMR 93, 95% confidence intervals [CI] 92-94), alcoholism (PMR 62, 95% CI 57-68), drugs (PMR 80, 95% CI 70-90), and more likely to die from cerebrovascular disease (PMR 105, 95% CI 104-107) and diabetes (PMR 107, 95% CI 105-109). HCPs aged 18-64 years were more likely to die by suicide (PMR 104, 95% CI 101-107), whereas those aged 65-90 years were less likely to die by suicide (PMR 84, 95% CI 77-91), with physicians (PMR 251, 95% CI 229-275) and other HCPs having high PMR for suicide. Among all HCPs, suicide PMR was similarly increased, whereas heart disease PMRs are similarly decreased among Black compared with those among White HCPs and those among male compared with those among female HCPs. HCPs as a group and specific types of HCPs demonstrate causes of mortality that differ in important ways from the general population. Race and gender-based trends in PMRs for key causes of mortality among HCPs suggest that employment in a health care field may not alter race and gender disparities noted among the general population.

Racial and Ethnic Differences in Awareness and Prevalence of Unidentified Cardiovascular Risk Factors Among Health System Employees.

PURPOSE: To evaluate awareness about cardiovascular (CVD) risk among a racially and ethnically diverse cohort of health system employees. DESIGN: Cross-sectional study. SETTING: Voluntary survey of health system employees during an annual CVD awareness and screening event. SUBJECTS: 759 health system employees. MEASURES: We performed initial CVD screening measurements (blood pressure, body mass index) and collected patient-reported answers to questions about their own CVD risk factors (hypertension, high cholesterol, diabetes, overweight, smoking, physical inactivity and family history of CVD) and whether or not they believed that CVD is preventable. Subjects were offered in-depth follow-up CVD screening (lipid panel, hs-CRP, hemoglobin A1c), if interested. ANALYSIS: Continuous measures were compared across sex and racial/ethnic subsets using a t test and analysis of variance technique. Univariable and multivariable logistic regression models were used to estimate the employee's willingness to undergo further comprehensive screening. RESULTS: African American, Hispanic, and Asian employees were younger than white employees (P < .0001). More than one-quarter of African Americans reported a history of hypertension, a higher rate than for other subgroups (P = .001). The rate of self-reported diabetes was highest in African American and Asian employees (P = .001). African Americans had a 54% reduced odds of electing to pursue follow-up CVD screening (odds ratio: .46, 95% confidence interval = .24-.91, P = .025). CONCLUSION: Presence of CVD risk factors and knowledge of their importance differ among racial and ethnic groups of health system employees in our cohort as does interest in pursuing follow-up screening once risk factors are identified. Development of evidence-based customization strategies by racial and ethnic group may improve understanding of and interest in CVD risk factors and advance prevention. The data from this study will inform future research and strategies for employee health promotion.

Racial Disparities in Obesity-Related Cardiovascular Mortality in the United States: Temporal Trends From 1999 to 2020.

Background Obesity is a major risk factor for cardiovascular disease, with differential impact across populations. This descriptive epidemiologic study outlines trends and disparities in obesity-related cardiovascular mortality in the US population between 1999 and 2020. Methods and Results The Multiple Cause of Death database was used to identify adults with primary cardiovascular death and obesity recorded as a contributing cause of death. Cardiovascular deaths were grouped into ischemic heart disease, heart failure, hypertensive disease, cerebrovascular disease, and other. Absolute, crude, and age-adjusted mortality rates (AAMRs) were calculated by racial group, considering temporal trends and variation by sex, age, and residence (urban versus rural). Analysis of 281 135 obesity-related cardiovascular deaths demonstrated a 3-fold increase in AAMRs from 1999 to 2020 (2.2-6.6 per 100 000 population). Black individuals had the highest AAMRs. American Indian or Alaska Native individuals had the greatest temporal increase in AAMRs (+415%). Ischemic heart disease was the most common primary cause of death. The second most common cause of death was hypertensive disease, which was most common in the Black racial group (31%). Among Black individuals, women had higher AAMRs than men; across all other racial groups, men had a greater proportion of obesity-related cardiovascular mortality cases and higher AAMRs. Black individuals had greater AAMRs in urban compared with rural settings; the reverse was observed for all other races. Conclusions Obesity-related cardiovascular mortality is increasing with differential trends by race, sex, and place of residence.

CKD-Associated Cardiovascular Mortality in the United States: Temporal Trends From 1999 to 2020.

Rationale & Objective: Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular (CV) mortality, but there are limited data on temporal trends disaggregated by sex, race, and urban/rural status in this population. Study Design: Retrospective observational study. Setting & Participants: The Centers for Disease Control and Prevention Wide-Ranging, Online Data for Epidemiologic Research database. Exposure & Predictors: Patients with CKD and end-stage kidney disease (ESKD) stratified according to key demographic groups. Outcomes: Etiologies of CKD- and ESKD-associated mortality between 1999 and 2000. Analytical Approach: Presentation of age-adjusted mortality rates (per 100,000 people) characterized by CV categories, ethnicity, sex (male or female), age categories, state, and urban/rural status. Results: Between 1999 and 2020, we identified 1,938,505 death certificates with CKD (and ESKD) as an associated cause of mortality. Of all CKD-associated mortality, the most common etiology was CV, with 31.2% of cases. Between 1999 and 2020, CKD-related age-adjusted mortality increased by 50.2%, which was attributed to an 86.6% increase in non-CV mortality but a 7.1% decrease in CV mortality. Black patients had a higher rate of CV mortality throughout the study period, although Black patients experienced a 38.6% reduction in mortality whereas White patients saw a 2.7% increase. Hispanic patients experienced a greater reduction in CV mortality over the study period (40% reduction) compared to non-Hispanic patients (3.6% reduction). CV mortality was higher in urban areas in 1999 but in rural areas in 2020. Limitations: Reliance on accurate characterization of causes of mortality in a large dataset. Conclusions: Among patients with CKD-related mortality in the United States between 1999 and 2020, there was an increase in all-cause mortality though a small decrease in CV-related mortality. Overall, temporal decreases in CV mortality were more prominent in Hispanic versus non-Hispanic patients and Black patients versus White patients.

Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial.

BACKGROUND: There is a paucity of randomized trials regarding diagnostic testing in women with suspected coronary artery disease (CAD). It remains unclear whether the addition of myocardial perfusion imaging (MPI) to the standard ECG exercise treadmill test (ETT) provides incremental information to improve clinical decision making in women with suspected CAD. METHODS AND RESULTS: We randomized symptomatic women with suspected CAD, an interpretable ECG, and ≥5 metabolic equivalents on the Duke Activity Status Index to 1 of 2 diagnostic strategies: ETT or exercise MPI. The primary end point was 2-year incidence of major adverse cardiac events, defined as CAD death or hospitalization for an acute coronary syndrome or heart failure. A total of 824 women were randomized to ETT or exercise MPI. For women randomized to ETT, ECG results were normal in 64%, indeterminate in 16%, and abnormal in 20%. By comparison, the exercise MPI results were normal in 91%, mildly abnormal in 3%, and moderate to severely abnormal in 6%. At 2 years, there was no difference in major adverse cardiac events (98.0% for ETT and 97.7% for MPI; P=0.59). Compared with ETT, index testing costs were higher for exercise MPI (P<0.001), whereas downstream procedural costs were slightly lower (P=0.0008). Overall, the cumulative diagnostic cost savings was 48% for ETT compared with exercise MPI (P<0.001). CONCLUSIONS: In low-risk, exercising women, a diagnostic strategy that uses ETT versus exercise MPI yields similar 2-year posttest outcomes while providing significant diagnostic cost savings. The ETT with selective follow-up testing should be considered as the initial diagnostic strategy in symptomatic women with suspected CAD. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT00282711.

Underrepresentation of women in cardiac imaging trials: A review.

Inclusion and equal representation of women in cardiovascular imaging trials are essential to provide insight into the factors impacting women's heart health and outcomes. Despite heart disease being the leading cause of mortality for women in the United States, women have been underrepresented in cardiovascular clinical trials, including imaging trials. Research demonstrates that women have key sex-specific differences in the pathophysiology of cardiovascular disease, the evolution of disease state, and disease manifestation (Solimene, 2010; Nevsky et al., 2011 [1,2]). This understanding and acknowledgment come decades after clinical providers have extrapolated data from cardiovascular disease clinical trials conducted primarily on Caucasian men, assuming the data were generalizable to sex, race, and ethnicity. The current cardiology society guidelines, which recommend optimal medical therapies for various cardiovascular diseases, are based on trials predominantly focused on men rather than women. Sex-based research, governmental and institutional task forces, and policies on gender equity have made inroads into the disproportionate number of women's enrollment in clinical research. The National Institutes of Health in the 1990s set forth requirements on incorporating women and minorities in research, including clinical trials (Mastroianni et al., 1994; Mieres et al., 2014 [3,4]). Continued progress is imperative to improve the gap in the number of women enrolled in clinical research trials.

Clinical role of the Duke Activity Status Index in the selection of the optimal type of stress myocardial perfusion imaging study in patients with known or suspected ischemic heart disease.

BACKGROUND: Exercise treadmill stress myocardial perfusion imaging (MPI) with single photon emission computed tomography is commonly used to evaluate the extent and severity of inducible ischemia as well as to risk stratify patients with suspected and known coronary artery disease (CAD). Failure to reach adequate stress, defined as not attaining age-appropriate metabolic equivalents (METs), can underestimate the extent and severity of ischemic heart disease, resulting in false negative results. This study evaluates the efficacy of the Duke Activity Status Index (DASI), a simple self-administered 12-item questionnaire, as a predictor of METs achieved by treadmill stress testing. METHODS: The DASI was prospectively administered to 200 randomly selected men and women referred to the nuclear cardiology laboratory at New York University Langone Medical Center for stress MPI. Each patient was asked to complete the 12-item DASI questionnaire independently. 136 patients underwent treadmill exercise with MPI and 64 had pharmacologic stress with MPI. The association between exercise capacity in METs as estimated by the DASI questionnaire and performance on the Bruce treadmill protocol in METS was compared using chi-square statistics. RESULTS: Over 70% of those patients whose DASI score predicted the ability to perform <10 METs were unable to exercise beyond stage 2 of the Bruce protocol (7 METs). For those whose DASI score predicted ability to perform >12.5 METs, over 80% of patients reached >stage 2 of the Bruce protocol with 40% reaching beyond stage 3 (10 METs). When patient age was incorporated into the calculation, a more linear relationship was observed between predicted and obtained METs. CONCLUSION: The DASI is a simple self-administered questionnaire which is a useful pretest tool to determine a patient's ability to achieve appropriate METs. In the nuclear cardiology laboratory, the DASI has the potential to guide selection of exercise treadmill vs pharmacologic stress and ultimately improve laboratory efficiency.