Disparities In Cardiovascular Disease Research Articles

COVID-19: An opportunity to engage African Americans and women in research on cardiovascular disease

IntroductionAfrican Americans (AA) have been disproportionately affected with the COVID-19 disease experiencing 30%-60% of the deaths, while only making up 13% of the US population. Early data suggest that pregnant women and those with cardiovascular disease (CVD) may experience worse outcomes with severe coronavirus infection. There is an urgent need to incorporate AA and female perspectives into the design of research on the CVD complications related to COVID-19. ObjectivesThe goal of this project was to incorporate perspectives of AA and female patients in developing research priorities and AN agenda related to COVID-19. Objectives included: (a) develop a strong, research-ready partnership capable of executing PCOR, (b) creation of a research agenda and a set of priorities on racial/sex-specific CVD disparities in COVID-19 which reflects the perspectives of AA's and women; (c) long-term objective is creation of a set of research questions suitable for clinical research using the AHA Registry. MethodsThe project used principles of active and adult learning within the framework of capacity building to build a strong, patient-centered vision of research needs. Different methods of obtaining patient input were used to identify questions suitable for research using the America Heart Association COVID-19 CVD Quality Improvement Registry: focus groups and town halls to identify concerns and interests vis-à-vis CVD and COVID research; narrative medicine methods collected compelling real-life, COVID-19 health stories; a research advisory council reviewed and prioritized research questions. ResultsOutcomes include a replicable method of obtaining patient-oriented input into the creation of a research agenda and a set of research priorities for COVID-19. Outputs include the establishment of a research advisory council and stakeholder training using the PCORI funded, PORTAL program resources; a catalogue of patient generated narratives on COVID-19 experiences in the voice of AAs and women, and a set of research questions suitable for research using the AHA Registry. ConclusionThe project created a research ready stakeholder network, ready to develop a research agenda about COVID-19.

Association between racial residential segregation and Black-White disparities in cardiovascular disease mortality

Racial residential segregation is associated with racial health inequities, but it is unclear if segregation may exacerbate Black-White disparities in cardiovascular disease (CVD) mortality. This study aimed to assess associations between Black-White residential segregation, CVD mortality rates among non-Hispanic (NH) Black and NH White populations, and Black-White disparities in CVD mortality. This cross-sectional study analyzed Black-White residential segregation, as measured by county-level interaction index, of US counties, county-level CVD mortality among NH White and NH black adults aged 25 years and older, and county-level Black-White disparities in CVD mortality in years 2014 to 2017. Age-adjusted, county-level NH Black CVD mortality rates and NH White cardiovascular disease mortality rates, as well as group-level relative risk ratios for Black-White cardiovascular disease mortality, were calculated. Sequential generalized linear models adjusted for county-level socioeconomic and neighborhood factors were used to estimate associations between residential segregation and cardiovascular mortality rates among NH Black and NH White populations. Relative risk ratio tests were used to compare Black-White disparities in the most segregated counties to disparities in the least segregated counties. We included 1,286 counties with ≥5% Black populations in the main analysis. Among adults aged ≥25 years, there were 2,611,560 and 408,429 CVD deaths among NH White and NH Black individuals, respectively. In the unadjusted model, counties in the highest tertile of segregation had 9% higher (95% CI, 1%-20% higher, P=.04) rates of NH Black CVD mortality than counties in the lowest tertile of segregation. In the multivariable adjusted model, the most segregated counties had 15% higher (95% CI, 0.5% to 38% higher, P=.04) rates of NH Black CVD mortality than the least segregated counties. In the most segregated counties, NH Black individuals were 33% more likely to die of CVD than NH White individuals (RR 1.33, 95% CI 1.32 to 1.33, P < .001). Counties with increased Black-White residential segregation have higher rates of NH Black CVD mortality and larger Black-White disparities in CVD mortality. Identifying the causal mechanisms through which racial residential segregation widens disparities in CVD mortality requires further study.

Low educational attainment is associated with higher all-cause and cardiovascular mortality in the United States adult population

IntroductionEducational attainment is an important social determinant of health (SDOH) for cardiovascular disease (CVD). However, the association between educational attainment and all-cause and CVD mortality has not been longitudinally evaluated on a population-level in the US, especially in individuals with atherosclerotic cardiovascular disease (ASCVD). In this nationally representative study, we assessed the association between educational attainment and the risk of all-cause and cardiovascular (CVD) mortality in the general adult population and in adults with ASCVD in the US.MethodsWe used data from the 2006–2014 National Death Index-linked National Health Interview Survey for adults ≥ 18 years. We generated age-adjusted mortality rates (AAMR) by levels of educational attainment (< high school (HS), HS/General Education Development (GED), some college, and ≥ College) in the overall population and in adults with ASCVD. Cox proportional hazards models were used to examine the multivariable-adjusted associations between educational attainment and all-cause and CVD mortality.ResultsThe sample comprised 210,853 participants (mean age 46.3), representing ~ 189 million adults annually, of which 8% had ASCVD. Overall, 14.7%, 27%, 20.3%, and 38% of the population had educational attainment < HS, HS/GED, Some College, and ≥ College, respectively. During a median follow-up of 4.5 years, all-cause age-adjusted mortality rates were 400.6 vs. 208.6 and 1446.7 vs. 984.0 for the total and ASCVD populations for < HS vs ≥ College education, respectively. CVD age adjusted mortality rates were 82.1 vs. 38.7 and 456.4 vs 279.5 for the total and ASCVD populations for < HS vs ≥ College education, respectively. In models adjusting for demographics and SDOH, < HS (reference = ≥ College) was associated with 40–50% increased risk of mortality in the total population and 20–40% increased risk of mortality in the ASCVD population, for both all-cause and CVD mortality. Further adjustment for traditional risk factors attenuated the associations but remained statistically significant for < HS in the overall population. Similar trends were seen across sociodemographic subgroups including age, sex, race/ethnicity, income, and insurance status.ConclusionsLower educational attainment is independently associated with increased risk of all-cause and CVD mortality in both the total and ASCVD populations, with the highest risk observed for individuals with < HS education. Future efforts to understand persistent disparities in CVD and all-cause mortality should pay close attention to the role of education, and include educational attainment as an independent predictor in mortality risk prediction algorithms.

Abstract 370: Corticosterone-mediated Associations Between Neighborhood Environment Perceptions and Lysosomal Acid Lipase Levels - Data From The Washington, D.C. Cardiovascular Health and Needs Assessment

Experiences of adverse social determinants of health (SDoH), like less favorable neighborhood environment perceptions, are associated with cardiovascular disease (CVD). Lysosomal acid lipase (LAL) plays an important role in lipid metabolism, and genetic LAL deficiency has been linked to CVD risk. We aimed to determine the potential relationship between neighborhood perceptions and LAL and to evaluate stress-related biomarkers as mediators of this relationship in the D.C. Cardiovascular Health and Needs Assessment cohort (60 African American participants, mean age 61yr, 93% female), biomarkers were measured using ELISA, and perceptions of neighborhood violence, physical and social environment, social cohesion, and safety were determined using validated questionnaires with higher scores indicating more favorable perceptions. We explored neighborhood perceptions-LAL relationships with regression models adjusted for BMI and ASCVD risk score and stratified by hyperlipidemia due to the potential confounding role of LDL. Mediation analysis was used to evaluate cortisol and corticosterone as potential mediators of the neighborhood perceptions-LAL relationship. Of the neighborhood perceptions measured, more favorable perceptions of physical and social environment associated with greater LAL (β=0.23, p=0.09); this association persisted only among participants without hyperlipidemia (β=0.42, p=0.04). Only corticosterone associated with both perceived physical and social environment and LAL (Figure); corticosterone mediated 73.1% of this relationship in all participants and 89.9% of this relationship in participants without hyperlipidemia. Our data highlight the relationship between perceived physical and social environment and LAL mediated by corticosterone. Results also emphasize the importance of future interdisciplinary work to better understand mechanisms by which SDoH and associated biomarkers contribute to CVD disparities.

Correction to: Locking the Revolving Door: Racial Disparities in Cardiovascular Disease.

HomeJournal of the American Heart AssociationAhead of PrintCorrection to: Locking the Revolving Door: Racial Disparities in Cardiovascular Disease Open AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessCorrectionPDF/EPUBCorrection to: Locking the Revolving Door: Racial Disparities in Cardiovascular Disease Originally published7 Apr 2023https://doi.org/10.1161/JAHA.122.027676Journal of the American Heart Association. 2023;0:e8383This article corrects the followingLocking the Revolving Door: Racial Disparities in Cardiovascular DiseaseIn the article by Gladys Velarde et al, “Locking the Revolving Door: Racial Disparities in Cardiovascular Disease,” which published online March 21, 2023 (J Am Heart Assoc. 2023;12:e025271. DOI: 10.1161/JAHA.122.025271), corrections were needed.The name of the 13th author, Ritu Thamman, was incorrectly listed in the published article as Ritu Thaman. This error has now been corrected.In the section Heterogeneity in CVD Risk Burden Within Groups, the authors mistakenly wrote “This is particularly relevant to Hispanic/Latino and Asian populations, the 2 largest racial and ethnic groups in the United States.” This has now been corrected to read “This is particularly relevant to Hispanic/Latino and Asian populations, 2 of the largest racial and ethnic groups in the United States.”The authors regret the errors.The online version of the article has been updated and is available here: https://www.ahajournals.org/doi/full/10.1161/JAHA.122.025271 Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesLocking the Revolving Door: Racial Disparities in Cardiovascular DiseaseGladys Velarde, et al. Journal of the American Heart Association;0 Article InformationMetrics Copyright © 2023 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.122.027676PMID: 37026547 Originally publishedApril 7, 2023 PDF download

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease.

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

Abstract P116: Racial/Ethnic and Nativity Differences in Cardiovascular Disease Mortality in the United States: Insights From the National Health Interview Survey 1999-2018

Background: Racial/ethnic disparities in cardiovascular disease (CVD) deaths continue to persist, despite advances in preventive strategies. Few studies have examined disparities in CVD deaths by nativity status (US- vs. foreign-born). Objective: To assess differences in CVD deaths by nativity status across racial/ethnic groups in the US. Methods: Using a cross-sectional design, we pooled data from 1999-2018 National Health Interview Survey, with linked death records through 2019. Outcome, cardiovascular related deaths (CVD &amp; CVA) was modelled, in years, as time from interview till year of death, or last date of follow-up (December 31, 2019). Nativity status was defined as US- or foreign-born. We used Cox proportional hazards regression to estimate differences in CVD deaths across racial/ethnic groups (White, Black, Asian, Indigenous American, and Hispanic adults) stratifying by nativity status. Models were sequentially adjusted for sociodemographic and CVD risk factors. Results: We included 172,896,665 adults (16% US-born, 84% foreign-born). During median 10 follow-up years, 3.41 CVD deaths /1,000person-years occurred. Among US-born adults, age-and sex-adjusted CVD death rates were 34% higher among Non-Hispanic Black adults (Hazard Ratio: 1.34; 95% CI, 1.29–1.39), 23% higher among Indigenous Americans (HR: 1.23; 95% CI, 1.00–1.52) compared to Non-Hispanic White adults [Table] . In the fully adjusted models, CVD death rates were 6% and 23% lower among Black (HR: 0.94 [95% CI, 0.89–0.99]) and Hispanic (HR: 0.77 [95% CI, 0.70–0.84]) adults. Compared to US-born White adults, CVD death was lower in foreign-born White (HR: 0.74; 95% CI, 0.66–0.82), Black (HR: 0.57; 95% CI, 0.45-0.73), Hispanic (HR: 0.55; 95% CI, 0.50–0.61), and Asian (HR: 0.61; 95% CI, 0.53–0.71) adults, respectively. Conclusions: Overall, CVD deaths were lower among foreign- than US-born adults. Although, there were some racial/ethnic differences in CVD deaths, we found evidence of persistent survival advantage among foreign-born adults.

Abstract P185: Disparities in Cardiovascular Disease and HIV Related Mortality in the United States

Introduction: Great strides have been made in microbiology and infectious diseases regarding HIV, revolutionizing the disease course. In the last forty years, advances in combination antiretroviral therapy (ART) have allowed HIV to become a chronic disease by dramatically decreasing the rates of acquired AIDS-defining illnesses. In contrast, a significant proportion of deaths in individuals infected with HIV due to cardiovascular events have been noted. Hypothesis: Disproportionate trends exist regarding CVD-related death within subpopulations of individuals infected with HIV in the United States (US). Methods: We utilized the CDC Wide-ranging Online Data for Epidemiologic Research database to ascertain mortality data using death certificate information from the National Vital Statistics System. All CVD-related deaths (ICD10 Codes: I00-I78) as the underlying cause of death and HIV (ICD10 Code: B20-B24) as the multiple causes of death from 1999 to 2020 were queried. The underlying cause of death is defined as the disease that directly led to death and multiple causes of death were defined as the diseases that contributed to death. Data were represented as age-adjusted mortality rates (AAMR) per 100,000 population and 95% confidence intervals, stratified by gender, racial, and geographic subgroups. Joinpoint regression (National Cancer Institute) was utilized for trend analysis and average annual percentage change (AAPC) calculation. Results: A total of 8,950 deaths were observed from 1999 to 2020. AAMR increased from 0.10 in 1999 to 0.15 in 2020 (p &lt;0.05). AAMR was more likely to be related to non-ischemic heart disease (0.06) compared to ischemic heart disease (0.05) (p &lt;0.05). AAMR was higher in males (0.20) compared with females (0.05) (p &lt;0.05). AAMR was disproportionately higher in Black populations (0.53) compared to White populations (0.08) (p &lt;0.05). No differences were observed for AAMR between Hispanic (0.12) and non-Hispanic (0.12) populations (p &gt;0.05). AAMR was highest in the Northeast (0.15) and South (0.16) regions, followed by Western (0.11) regions, then finally the Midwest (0.06) regions (p &lt;0.05). Cumulative AAPC from 1999 to 2020 was calculated at +1.7% (p &lt;0.05) with a significant inflection point in 2010. AAPC increased significantly among male subgroups (+1.5%), Black subgroups (+0.8%), White subgroups (+1.6%), metro regions (+1.7%), Midwest regions (+2.3%), and Southern regions (+2.1%) (p &lt;0.05), however, AAPC was not significantly different among female subgroups, Hispanic and non-Hispanic populations, non-metro regions, Northeast regions, and Western regions (p &gt;0.05). Conclusion: Disparities linked to CVD-related death in the population infected with HIV exist among various gender, racial, and geographic subgroups. Research targeted at CVD prevention and management in this population is tantamount to addressing these healthcare disparities.

Abstract P363: Knowledge of COVID-19-Related Risk Factors and Conditions Among Asian American, Native Hawaiian, and Pacific Islander Adults, February-April 2022

Introduction: Communities of color, including Asian Americans (AAs), Native Hawaiians and Pacific Islanders (NH/PIs), experienced higher rates of COVID-19 infection, hospitalization and death compared to white populations during the early pandemic. Further, there are known disparities in cardiovascular disease (CVD) risk factors among AA and NH/PI groups that existed pre-pandemic (e.g., greater prevalence of diabetes among Filipino and Asian Indian compared to white adults). These outsized risks are combined with the increased experience of anti-Asian racism in this period along with historical distrust of health institutions, and legacies of structural racism that have made communities of color vulnerable to the pandemic. The purpose of this study was to understand knowledge of COVID-19-related conditions among AA and NH/PI ethnic groups, in order to anticipate and mitigate further COVID-19 and CVD disparities. Hypothesis: We hypothesize that knowledge of post-COVID-19 conditions and variants would vary by disaggregated AA and NH/PI ethnic group. Methods: The National COVID-19 Rapid Needs Assessment was conducted among AA and NH/PI adults from February to April 2022 with the help of ten community partners (n = 1,358; 1,197 AAs and 153 NH/PIs). The survey was primarily administered online in English and 11 Asian languages. We examined the following COVID-19 knowledge outcomes: vaccine breakthrough infections, COVID-19 variants, and long COVID. Responses included: ‘I know a lot about it,’ ‘I know a moderate amount about it,’ ‘I have heard of it, but don’t know much about it,’ and ‘I haven’t heard of it.’ Outcomes were disaggregated by seven AA (Chinese, Taiwanese, Filipino, Japanese, Korean, Vietnamese, South Asian) and two NH/PI (Polynesian, Micronesian) subgroups. Additional analyses will examine differences in knowledge based on misinformation and disinformation in the absence of timely, language concordant COVID-19 information. Results: Among AAs overall, 14.0% had not heard of vaccine breakthrough infections; 7.4% had not heard of COVID-19 variants; and 11.7% had not heard of long COVID. South Asian adults reported the lowest knowledge of COVID-19, while Filipinos reported the highest knowledge. Among NH/PI adults, 27.2% had not heard of vaccine breakthrough infections; 6.6% had not heard of COVID-19 variants; and 28.4% had not heard of long COVID. Both NH/PI subgroups reported very low knowledge of breakthrough infections and long COVID. Conclusion: Findings indicate COVID-19-related knowledge disparities across AA and NH/PI ethnic subgroups which may be more pronounced among South Asian and NH/PI communities. The COVID-19 pandemic will exacerbate known CVD health disparities if the pandemic mitigation strategies (e.g., disaggregated racial/ethnic data collection) are not inclusive of communities of color, immigrants and limited English fluent populations.

Abstract 04: Neighborhood Social Vulnerability Associated With Increased Hypertension and Cardiovascular Disease in Port-au-Prince: Findings From the Haiti Cardiovascular Disease Cohort Study

Introduction: Cardiovascular disease (CVD) is the leading cause of mortality in low-income countries (LICs). Neighborhood social vulnerability has been associated with increased CVD risk in high-income countries, but the relationship is unknown in LICs. Our objective was to determine the association between neighborhood social vulnerability and prevalent CVD in urban Haiti. Hypothesis: We hypothesize that adults living in neighborhoods with increased social vulnerability will have a greater prevalence of hypertension (HTN) and CVD. Methods: We used cross-sectional enrollment data from the Haiti CVD Cohort study, a population-based cohort of adults ≥18 years living in Port-au-Prince distributed across 97 census blocks. To quantify vulnerability, we created a Haiti-specific Neighborhood Social Vulnerability Index (NSVI) based on the US CDC Social Vulnerability Index. The NSVI included three socioeconomic variables (income, sex, education), two household variables (single parent household, household with child &lt;18 years), and six neighborhood stress and well-being variables (neighborhood cohesion, neighborhood violence, perceived stress, food insecurity, depression, social support). Each variable was determined using validated questionnaires. NSVI was calculated for each census block, which were stratified into quartiles. HTN was defined as SBP ≥140 mmHg, DBP ≥90, or on antihypertensive medications; CVD included heart failure, stroke, myocardial infarction, and angina, defined using adjudicated criteria. HTN and CVD prevalence were calculated for each NSVI quartile. Associations between NSVI quartile and HTN or CVD were quantified using individual-level multivariate logistic regression to adjust for confounders. Results: Among 2932 participants, median age was 40 years (IQR 28-55) and 58% were female. Age-standardized prevalence of HTN and CVD was 32.3% and 13.8%, respectively. The age-standardized prevalence of HTN and CVD was 35.7% and 17.3% across 4 th NSVI quartile blocks, compared to 29.1% and 14.1% across 1 st quartile NSVI blocks (p &lt; 0.001). After adjusting for age, BMI, smoking, and alcohol use, participants living in 4 th NSVI quartile blocks had a greater risk of HTN (Adjusted Odds Ratio (aOR) 1.42; 95% CI 1.07-1.88; p-value 0.01) and CVD (aOR 1.36; CI: 0.99-1.88; p-value 0.06) compared to participants in the 1 st NSVI quartile blocks. NSVI was significantly associated with HTN in males but not females; conversely, NSVI was significantly associated with CVD in females and not males. Conclusions: Individuals living in neighborhoods with the greatest social vulnerability had a higher prevalence of HTN and CVD. Even in a setting of severe poverty such as urban Haiti, gradients in social vulnerabilities are associated with CVD disparities. Screening for social vulnerabilities should be incorporated into CVD prevention and treatment interventions in LICs.

Abstract P149: Police Contact in Adolescence and Healthy Lifestyle Patterns During the Transition to Adulthood: A Longitudinal Study

Background: Considerable work finds that adverse childhood experiences may predispose cardiovascular disease (CVD) in adulthood. While youth contact with police is an increasingly common early life adversity with known health impacts, it remains understudied in cardiovascular research. This prospective study investigated whether encounters with police in adolescence were associated with CVD-related lifestyle factors during the transition to adulthood. Methods: Data came from the Panel Study of Income Dynamics Child Development and Transition to Adulthood Supplements (N=2,361). In 2002 and 2007, participants aged 10-19y reported how often they were stopped and questioned by the police in the past 6 months (never, once, 2+ times). In 2005-2019, biennial surveys were completed from age 18-28y assessing 5 healthy lifestyle factors: body mass index 18.5-25 kg/m 2 , 8-11h of sleep per night for those ≤19y or 6-9h of sleep per night for those ≥20y, non-smoking, no binge drinking, and engaging in regular physical activity. Participants who reported having these factors at each available follow-up assessment were defined as sustaining healthy patterns over time. Poisson regression models evaluated associations between police contact and sustained healthy patterns of both individual lifestyle factors and multiple factors (range=0-5). Sensitivity analyses excluded youth who reported being arrested by police. Differences by race and gender were evaluated via interaction terms. Results: In the overall sample, 9% of youth were stopped by police once and 9% twice or more. Separately, 5% reported a history of arrest. Both police stops and arrests were more common among Black youth (1 stop: 11%, 2+ stops: 11%, arrest: 8%) than White youth (1 stop: 7%, 2+ stops: 7%, arrest: 2%). After adjusting for study covariates, frequent police stops were associated with a lower likelihood of maintaining healthy sleep patterns (IRR 1 stop =0.79, 95% CI=0.52, 1.20; IRR 2+ stops = 0.42, 95% CI=0.23, 0.77), abstaining from binge drinking in young adulthood (IRR 1 stop =0.86, 95% CI=0.70, 1.04; IRR 2+ stops =0.74, 95% CI=0.59, 0.92), and sustaining healthy patterns of multiple lifestyle factors (IRR 1 stop =0.91, 95% CI=0.75, 1.09; IRR 2+ stops =0.71, 95% CI=0.58, 0.88). Associations with other lifestyle factors were comparable in magnitude but characterized by wide confidence intervals. Nearly identical associations were observed when excluding youth with a history of arrest. Tests for interaction found no evidence of moderation by race or gender. Conclusions: Youth contact with police is related to unhealthy lifestyle patterns during the transition to adulthood, which may have important consequences for cardiovascular health across the lifespan. Given the disproportionate burden of police contact experienced by Black youth, future research should consider its potential role as an early driver of CVD disparities.

Medicaid Expansion and Racial-Ethnic and Sex Disparities in Cardiovascular Diseases Over 6 Years: A Generalized Synthetic Control Approach.

Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex. Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasi-experimental approach, to estimate effects. Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19). Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates.

Blood Pressure Control Among Black and White Adults Following a Quality Improvement Program in a Large Integrated Health System

A higher percentage of non-Hispanic Black (hereinafter, Black) adults vs non-Hispanic White (hereinafter, White) adults with hypertension have uncontrolled blood pressure (BP) contributing to racial and ethnic disparities in cardiovascular disease. In 2010, Kaiser Permanente Southern California began implementing quality improvement (QI) strategies aimed at reducing this disparity. To examine the change in BP control between Black and White patients before and after the implementation of a QI program. A QI quasi-experimental, difference-in-difference analysis was conducted of Kaiser Permanente Southern California patients 18 years or older included in the population care management hypertension registry. The study was conducted from December 31, 2008, to December 31, 2019. Data analysis was performed from November 20, 2020, to November 7, 2022. Quality improvement program implementation began in 2010. Blood pressure control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) was assessed using the last outpatient BP measurement in each calendar year. Changes in BP control between Black and White patients from before (2008-2009) to after (2016-2019) implementation of the QI program were examined using a difference-in-difference analysis. Blood pressure control disparities from 2008 through 2019 by age, sex, race and ethnicity, and factors associated with BP control were examined. The number of patients with hypertension increased from 624 094 in 2008 (mean [SD] age, 61.8 [13.5] years; 330 551 [53.0%] female patients; 89 407 [14.3%] Black and 284 116 [45.5%] White patients) to 855 257 in 2019 (mean [SD] age, 64.5 [13.6] years; 444 422 [52.0%] female patients; 107 054 [12.5%] Black and 331 932 [38.8%] White patients). Blood pressure control increased an absolute 4.6% (95% CI, 4.3%-4.8%) among Black patients and 2.1% (95% CI, 2.0%-2.2%) among White patients from before to after the QI program implementation (difference-in-difference: 2.5%; 95% CI, 2.2%-2.8%). The largest reduction in BP control disparity between Black and White female patients was for those aged 50 to 64 years (difference-in-difference: 3.8%; 95% CI, 3.2%-4.4%) and for those aged 18 to 49 years between Black and White male patients (difference-in-difference: 4.2%; 95% CI, 3.0%-5.5%). The proportion of BP control among Black male patients aged 18 to 49 years was the lowest throughout 2008-2019 compared with male and female patients in other age and racial and ethnic groups. In 2019, uncontrolled BP was more common among Black vs White patients (prevalence ratio: 1.13; 95% CI, 1.12-1.14). This QI program noted that disparities in BP control between Black and White patients were decreased but not eliminated following implementation of QI strategies aimed at reducing disparities in BP control. These findings suggest that more focused interventions may be needed to increase BP control among Black individuals.

Abstract C032: Increased allostatic load is associated with castrate-resistance and de novo metastatic disease in prostate cancer

Abstract Introduction: Allostatic load (AL) is a composite measure of chronic stress including cardiovascular, immune, and metabolic biomarkers. AL has previously been associated with health disparities in cardiovascular disease, metabolic syndrome, and certain malignancies. However, there are no prior publications to the best of our knowledge evaluating the association of AL and clinical outcomes in patients with advanced prostate cancer (PCa). Methods: We identified 139 subjects with metastatic or biochemically recurrent (BCR) PCa treated at the University of Illinois Hospital and Health Sciences System between January 2015 and May 2022. Subjects were assigned AL scores based on retrospective assessment of 9 biomarkers (systolic and diastolic blood pressure, heart rate, alkaline phosphatase, albumin, creatinine, body mass index, glucose, white blood cell count) collected at the time of diagnosis of advanced disease. Subjects were assigned a total AL score whereby each of the individual 9 biomarkers were given a value of 0 or 1 if threshold value was met. Results: Of the 139 subjects, the median age at PCa diagnosis was 63. The majority were African American (65.4%), 14.4% were Hispanic or Latino, 12.2% were white and non-Hispanic or Latino, and race/ethnicity was other or unknown for 7.9%. A majority (62.6%) had localized or regional nodal disease at diagnosis but later developed metastases or BCR, while 37.4% had de novo metastatic disease. Those with de novo metastatic disease had a higher mean AL score compared to those who had localized or regional nodal disease at diagnosis (2.62 vs. 2.08, p=0.03). Nearly all of the subjects (98.6%) received androgen deprivation therapy (ADT) while 1.4% had surgical castration. Most (66.2%) had local therapies such as surgery or radiation prior to or in addition to ADT. A minority (39.6%) developed castrate-resistant disease while 60.4% did not. For subjects who developed castrate-resistant disease, median time to castrate-resistance was 31 months. Those who developed castrate-resistant disease had a higher mean AL score compared to those who did not (2.58 vs. 2.08, p=0.03). In the study population, 25.9% had a low sum Gleason score (≤7) at diagnosis, 46.0% had a high sum Gleason score (≥8) at diagnosis, and 28.1% did not have a Gleason score available at diagnosis. Subjects with a high sum Gleason score had higher mean AL compared to those with low sum Gleason scores, though this finding did not reach statistical significance (2.47 vs. 1.94, p=0.06). In our study, 32 out of 139 subjects had at least one biomarker missing from their records and therefore not included in the subject’s AL score. The most common biomarkers missing were albumin and alkaline phosphatase. Discussion: In our pilot, single-institution study, higher AL may be associated with more aggressive phenotypes of PCa including de novo metastatic disease, earlier progression to castrate-resistance, and higher Gleason scores. Prospective studies are needed to further validate the role AL plays in PCa aggressiveness. Citation Format: Michael Weinfeld, Ryan Nguyen, Frank Weinberg, Vijayakrishna Gadi, Natalie Reizine. Increased allostatic load is associated with castrate-resistance and de novo metastatic disease in prostate cancer [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C032.

Abstract 15192: Neighborhood Social Vulnerability Predicts Cardiovascular Disease Outcomes Through Pro-Inflammatory Risk Factors

Introduction: Emerging evidence suggests that neighborhood adverse characteristics are linked to nationwide disparities in cardiovascular disease (CVD) incidence and mortality. However, it is unclear if this association is linked to disease progression and outcomes in people with established CVD. Hypothesis: We hypothesized that in patients with CVD, neighborhood social adversity, measured as social vulnerability index (SVI) predicts incident cardiovascular events at least partly through pro-inflammatory. Methods: A total of 4150 participants enrolled in the Emory Cardiovascular Biobank, residential addresses were geocoded according to the census tract and SVI was determined using the Center for Disease Control data. Serum hs-C-reactive protein (hsCRP) levels were measured during enrollment and participants were followed up for incident myocardial infarction (MI) and cardiovascular death. Subdistribution hazard models were used to investigate the association between SVI and the study endpoint. A mediation analysis was performed to evaluate whether hsCRP levels underly this association. Results: Mean age was 63 years, 24% Black, and 64% were women. During a median 5 year follow-up, there were 904 (22%) adverse events. SVI and hsCRP were correlated (r=0.12, P&lt;0.001). After adjustment for age, race, sex,hypertension, diabetes mellitus, body mass index, prior MI, prior heart failure, renal function, smoking, statin and aspirin use, participants in the highest SVI quartile (most socially vulnerable), had a 31% (95%CI, 4%,64%) higher risk of CV death/MI compared to those in the lowest quartile. The risk was attenuated and became insignificant after adjusting for the hsCRP 23% (CI -3%, 54%). Serum hsCRP levels mediated 61% of the association between SVI and adverse events. Conclusions: Neighborhood social vulnerability is an independent risk factor for adverse outcomes in CVD, that is at least in part mediated through increased systemic inflammation. Neighborhood social vulnerability may explain some of the residual risk observed in patients with CVD.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association.

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

Race and outcomes after percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

Current studies show similar in-hospital outcomes following percutaneous coronary intervention (PCI) between Black and White patients. Long-term outcomes and the role of individual and community-level socioeconomic factors in differential risk are less understood. We linked clinical registry data from PCIs performed between January, 2013 and March, 2018 at 48 Michigan hospitals to Medicare Fee-for-service claims. We analyzed patients of Black and White race. We used propensity score matching and logistic regression models to estimate the odds of 90-day readmission and Cox regression to evaluate the risk of postdischarge mortality. We used mediation analysis to evaluate the proportion of association mediated by socioeconomic factors. Of the 29,317 patients included in this study, 10.28% were Black and 89.72% were White. There were minimal differences between groups regarding post-PCI in-hospital outcomes. Compared with White patients, Black patients were more likely to be readmitted within 90-days of discharge (adjusted OR 1.62, 95% CI [1.32-2.00]) and had significantly higher risk of all-cause mortality (adjusted HR 1.45, 95% CI 1.30-1.61) when adjusting for age and gender. These associations were significantly mediated by dual eligibility (proportion mediated [PM] for readmission: 11.0%; mortality: 21.1%); dual eligibility and economic well-being of the patient's community (PM for readmission: 22.3%; mortality: 43.0%); and dual eligibility, economic well-being of the community, and baseline clinical characteristics (PM for readmission: 45.0%; mortality: 87.8%). Black patients had a higher risk of 90-day readmission and cumulative mortality following PCI compared with White patients. Associations were mediated by dual eligibility, community economic well-being, and traditional cardiovascular risk factors. Our study highlights the need for improved upstream care and streamlined postdischarge care pathways as potential strategies to improve health care disparities in cardiovascular disease.

Health Care Disparities Involved In Establishing Functional Hemodialysis Vascular Access

In some patients, arteriovenous (AV) fistulas and AV grafts mature quickly after the initial surgery and can last for several years. In other patients, AV sites never fully mature, or patients may require additional surgical interventions. Health care disparities in cardiovascular disease among racial groups is well-documented, and it was suspected that racial backgrounds may influence patient risk for requiring additional surgeries in order to reach AV access maturity. The goal of this study was to evaluate the impact of racial demographics on risk of patients requiring additional surgical interventions after their first fistula or graft creation surgery.

Global, regional and national trends in statin utilisation in high-income and low/middle-income countries, 2015–2020

ObjectivePrior studies have reported inequitable global access to essential medicines for cardiovascular disease (CVD) prevention, especially statins. Here we examine recent trends and disparities in statin utilisation at the income...

Inequalities by Income in the Prevalence of Cardiovascular Disease and Its Risk Factors in the Adult Population of Catalonia.

BackgroundUnderstanding the magnitude of cardiovascular disease (CVD) inequalities is the first step toward addressing them. The linkage of socioeconomic and clinical data in universal health care settings provides critical information to characterize CVD inequalities.Methods and ResultsWe employed a prospective cohort design using electronic health records data from all residents of Catalonia aged 18+ between January and December of 2019 (N=6 332 228). We calculated age‐adjusted sex‐specific prevalence of 5 CVD risk factors (diabetes, hypertension, hyperlipidemia, obesity, and smoking), and 4 CVDs (coronary heart disease, cerebrovascular disease, atrial fibrillation, and heart failure). We categorized income into high, moderate, low, and very low according to individual income (tied to prescription copayments) and receipt of welfare support. We found large inequalities in CVD and CVD risk factors among men and women. CVD risk factors with the largest inequalities were diabetes, smoking, and obesity, with prevalence rates 2‐ or 3‐fold higher for those with very low (versus high) income. CVDs with the largest inequalities were cerebrovascular disease and heart failure, with prevalence rates 2 to 4 times higher for men and women with very low (versus high) income. Inequalities varied by age, peaking at midlife (30–50 years) for most diseases, while decreasing gradually with age for smoking.ConclusionsWe found wide and heterogeneous inequalities by income in 5 CVD risk factors and 4 CVD. Our findings in a region with a high‐quality public health care system and universal coverage stress that strong equity‐promoting policies are necessary to reduce disparities in CVD.