Racial and Ethnic Group Underrepresentation in Studies of Adverse Pregnancy Outcomes and Cardiovascular Risk.

Abstract

HomeJournal of the American Heart AssociationVol. 11, No. 5Racial and Ethnic Group Underrepresentation in Studies of Adverse Pregnancy Outcomes and Cardiovascular Risk Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessLetterPDF/EPUBRacial and Ethnic Group Underrepresentation in Studies of Adverse Pregnancy Outcomes and Cardiovascular Risk Sofia E. Gomez, MD, Ashish Sarraju, MD and Fatima Rodriguez, MD, MPH Sofia E. GomezSofia E. Gomez https://orcid.org/0000-0002-0900-6519 Department of Medicine, , Stanford University School of Medicine, , Stanford, , CA Search for more papers by this author , Ashish SarrajuAshish Sarraju https://orcid.org/0000-0003-1649-2110 Division of Cardiovascular Medicine and Cardiovascular Institute, , Department of Medicine, , Stanford University School of Medicine, , Stanford, , CA Search for more papers by this author and Fatima RodriguezFatima Rodriguez * Correspondence to: Fatima Rodriguez, MD, MPH, Division of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Center for Academic Medicine, Stanford, CA 94304‐5687. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0002-5226-0723 Division of Cardiovascular Medicine and Cardiovascular Institute, , Department of Medicine, , Stanford University School of Medicine, , Stanford, , CA Search for more papers by this author Originally published22 Feb 2022https://doi.org/10.1161/JAHA.121.024776Journal of the American Heart Association. 2022;11:e024776Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 22, 2022: Ahead of Print Adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery are pathologic adaptations to pregnancy. These events place women at increased risk of peripartum cardiomyopathy, stroke, seizure, and stillbirth in the short term and chronic kidney disease or cardiovascular disease (CVD) in the long term.1, 2 Recent guidelines on APOs have highlighted stark racial and ethnic disparities in cardiovascular risk and outcomes.3 Hypertensive disorders of pregnancy occur more frequently in Black women (including a 3‐fold higher mortality from preeclampsia) compared with White women.3, 4 Asian (especially Indian, Filipina, and Southeast Asian) women experience the highest rates of gestational diabetes of any racial or ethnic group.3, 4 Peripartum cardiomyopathy has a prevalence of ≈11.8 in 10 000 births, disproportionally impacting Black women.4 Given these documented disparities, diverse racial and ethnic representation in studies of APOs and CVD is crucial to ensure generalizability and equity when developing preventive strategies and treatment recommendations.We aimed to evaluate gaps in the reporting and representation of participant‐level race and ethnicity in studies of APOs and CVD informing the most contemporary guidelines, namely those cited in the 2021 American Heart Association’s (AHA’s) scientific statement on APOs and CVD risk.2Data supporting the findings of this study are available on request from the corresponding author. Two authors (S.E.G. and A.S.) reviewed cited studies in the 2021 AHA statement.2 Original studies and those within cited meta‐analyses were evaluated for study type (trial versus cohort), location (United States versus non–United States), and participant‐level racial and ethnic data. Racial and ethnic representation among pooled US studies was compared with 2010 and 2020 US Census estimates using the two‐proportion z test. Institutional review board approval was not obtained because public articles were reviewed.We reviewed 85 studies published between 2000 and 2019; all were observational studies investigating the correlation between APOs and either composite CVD (coronary artery disease, myocardial infarction, stroke, congestive heart failure), CVD mortality broadly (77 studies), or coronary artery disease and stroke (7 studies). Only 16 (19%) reported participant‐level racial and ethnic information. Only 12 reported White representation, 9 reported Black representation, 8 reported Hispanic representation, 5 reported Asian representation, 2 reported Aboriginal representation, 1 reported Jewish/Bedouin representation, and 7 reported “other” representation. No studies reported Pacific Islander, American Indian, or Alaska Native participation. Only 1 study disaggregated Asian data; none disaggregated Hispanic data. Fourteen (16%) studies included a US cohort, and 11 reported participant‐level race and ethnicity.Among US studies, White representation was 94.7% and 120.4% of expected compared with 2010 and 2020 US Census data, respectively (Figure, studies: 74.2%; 2010 Census: 78.4%; 2020 Census: 61.6%; P<0.001). Black representation was 75.4% and 79.2% of expected compared with 2010 and 2020 Census data, respectively (studies: 9.8%; 2010 Census: 13.0%; 2020 Census: 12.4%; P<0.001). Hispanic and Asian participants were also underrepresented compared with 2010 and 2020 Census estimates, with participation of 82.5% and 72.0% of expected for Hispanic groups and 63.4% and 51.9% for Asian groups, respectively.Contemporary studies of APOs and CVD cited in the 2021 AHA statement on APOs and CVD risk were limited, observational, mostly non‐US studies that underreported racial and ethnic data and lacked disaggreopgated race and ethnicity data. US studies underrepresented Black, Hispanic, and Asian groups compared with US Census population estimates.APOs and CVD heterogeneously and disproportionately affect historically disenfranchised groups.3 Yet, guideline‐informing evidence linking APOs and CVD lacked adequate racial and ethnic reporting and representation. While a small number of studies provided detailed reporting, overall reporting was suboptimal with minimal disaggregation by subgroups. These findings are consistent with disparities seen in cardiovascular trials among major disease states including dyslipidemia.5 Moreover, US studies had no reporting for Pacific Islanders, American Indians, and Alaska Natives despite prior literature suggesting a high burden of adverse cardiovascular outcomes and limited access to prenatal care in these groups. The need to improve study reporting and representation may be most crucial among these underrepresented groups. Concerted scientific and public health efforts focused on APOs and cardiovascular health in these groups are warranted. Finally, limited US‐based data (16% of total studies) further limits generalizability. Overall, inadequate national, racial, and ethnic representation may lead to inequitable study of the APO‐CVD relationship.This study has certain limitations. We included studies cited within the 2021 AHA statement, which have high visibility likely to guide clinical practice but may not be comprehensive. Given inconsistent reporting, we were unable to disaggregate data including for Asian participants and non‐Hispanic versus Hispanic ethnicity. Since the APO‐CVD relationship is understudied, available studies may be low in number. Nevertheless, these findings are crucial indicators of current racial and ethnic disparities in study reporting and representation in women’s cardiovascular health.In conclusion, we found significant underreporting and underrepresentation of diverse racial and ethnic groups among guideline‐informing studies of APOs and CVD. Improving diverse participant reporting and representation in studies on APOs and CVD across the life course is necessary to inform CVD prevention for these high‐risk women.Sources of FundingDr Ashish Sarraju received support from the American Heart Association (grant 20SFRN35360178). Dr Fatima Rodriguez received support from the National Heart, Lung, and Blood Institute, National Institutes of Health (1K01HL144607), and the American Heart Association/Robert Wood Johnson Harold Amos Medical Faculty Development Program.DisclosuresNone.Download figureDownload PowerPointFigure 1. Racial and ethnic representation among pooled US study participants per 2010 and 2020 US Census estimates.A, Proportion of studies reporting participant‐level racial and ethnic data. B, Adverse pregnancy outcomes (APOs) by racial and ethnic group, using gestational diabetes prevalence data from Northern California cohort 1995 to 2004 and preeclampsia incidence data from New York City cohort 1993 to 2002.3 GDM indicates gestational diabetes; and PE, preeclampsia.Footnotes* Correspondence to: Fatima Rodriguez, MD, MPH, Division of Cardiovascular Medicine, Stanford University, 453 Quarry Road, Center for Academic Medicine, Stanford, CA 94304‐5687. E‐mail: [email protected]edu*A. Sarraju and F. Rodriguez are co‐senior authors.For Sources of Funding and Disclosures, see page 3.References1 Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella‐Tommasino J, Forman DE, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 139:e1082–e1143. doi: 10.1161/CIR.0000000000000625LinkGoogle Scholar2 Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021; 143:e902–e916. doi: 10.1161/cir.0000000000000961LinkGoogle Scholar3 Balla S, Gomez SE, Rodriguez F. Disparities in cardiovascular care and outcomes for women from racial/ethnic minority backgrounds. Curr Treat Options Cardiovasc Med. 2020; 22:75. doi: 10.1007/s11936‐020‐00869‐zCrossrefMedlineGoogle Scholar4 Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, et al. Heart disease and stroke statistics‐2021 update: a report from the American Heart Association. Circulation. 2021; 143:e254–e743. doi: 10.1161/CIR.0000000000000950LinkGoogle Scholar5 Sarraju A, Valencia A, Knowles JW, Maron DJ, Rodriguez F. Diverse racial/ethnic group underreporting and underrepresentation in high‐impact cholesterol treatment trials. Circulation. 2021; 143:2409–2411. doi: 10.1161/CIRCULATIONAHA.120.050034LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 1, 2022Vol 11, Issue 5Article InformationMetrics Copyright © 2022 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.121.024776PMID: 35191322 Manuscript receivedNovember 18, 2021Manuscript acceptedJanuary 5, 2022Originally publishedFebruary 22, 2022 Keywordscardiovascular risk factorsadverse pregnancy outcomesracial and ethnic disparitiesPDF download SubjectsCardiovascular DiseasePregnancyRace and EthnicityRisk FactorsWomen, Sex, and Gender