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.

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.

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.

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.

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.

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.

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.

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.

The Association of Structural Inequities and Race With Out-of-Hospital Sudden Death During the COVID-19 Pandemic.

[Figure: see text].

Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine.

PROBLEM: Racism and bias are fundamental causes of health inequities, and they negatively affect the climate of academic medical institutions across the United States. APPROACH: In 2019, the Zucker School of Medicine and Northwell Health piloted a virtual reality (VR) racism experience as a component of professional development for medical school and health system leaders, faculty, and staff. Participants experienced a 60-minute, interactive, large-group session on microaggressions and, as individuals, a 20-minute VR module. These were followed by group reflection and debriefing. The sessions, developed in collaboration with a VR academic team, represented a response to institutional climate assessment surveys, which indicated the need for expanded professional training on cross-cultural communication and enhancing inclusion. OUTCOMES: In October 2019, 112 faculty and staff participated in the workshop. On a postworkshop survey, completed by 76 participants (67.9%), most respondents (90.8%) reported feeling engaged in the VR experience. Additionally, the majority agreed that VR was an effective tool for enhancing empathy (94.7%), that the session enhanced their own empathy for racial minorities (85.5%), and that their approach to communication would change (67.1%). In open-ended responses, participants frequently conveyed enthusiasm, powerful emotional and physiologic responses, and enhanced empathy. They also suggested more time for follow-up discussions. NEXT STEPS: Next steps include assessing the scalability of the VR module; determining effective complementary engagements; and measuring the module's longitudinal effects on racial empathy, discrimination, and institutional climate. As VR becomes more common in medical education, developing VR modules to address other forms of discrimination (e.g., sexism, homophobia) could also benefit the institutional climates of medical schools and health systems as academic medicine continues to build toward health equity.