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.

Mortality in ST-segment elevation myocardial infarction patients without standard modifiable risk factors: A race disaggregated analysis.

Background: Individuals who present with STEMI without the standard cardiovascular risk factors (SMuRFs) of diabetes, hypercholesterolemia, hypertension, and smoking, coined SMuRF-less are not uncommon. Little is known about their outcomes as a cohort and how they differ by race. Methods & Results: We identified 431,615 admissions with STEMI in the National Inpatient Sample (NIS) database 2015-2018, including patients with ≥ 1 SMuRF (n = 369,870) and those who were SMuRF-less (n = 234,745). SMuRF-less patients presented at a similar age (median age 63y vs 63y), were less likely to be female (33.6 % vs 34.6 %) and were almost twice as likely to present as a cardiac arrest (13.7 % vs 7.0 %), than those with ≥ 1 SMuRFs. SMuRF-less patients were less frequently in receipt of ICA (71.3 % vs 83.8 %) and PCI (58.0 % vs 72.2 %) compared to those with ≥ 1 SMuRF. Our race disaggregated analysis showed ethnic minority SMuRF-less patients were less likely than White patients to receive ICA and PCI, which was most apparent in Black patients with reduced odds of ICA (OR: 0.47, 95 % CI: 0.43-0.52) and PCI (OR: 0.46, 95 % CI: 0.52-0.50). Similarly, in ethnic minority subgroups within the SMuRF-less cohort, mortality and MACCE were significantly higher than in White patients. This was most profound in Black patients with in-hospital mortality (OR: 1.90, 95 % CI: 1.72-2.09) and MACCE (OR: 1.63, 95 % CI: 1.49-1.78) compared to White patients. Conclusion: Ethnic Minority SMuRF-less patients were less likely than White SMuRF-less patients to receive ICA and PCI and had worse mortality outcomes.

Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration.

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)-physicians, nurses and allied professionals-can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement.

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health.

Following decades of decline, maternal mortality began to rise in the United States around 1990-a significant departure from the world's other affluent countries. By 2018, the same could be seen with the maternal mortality rate in the United States at 17.4 maternal deaths per 100 000 live births. When factoring in race/ethnicity, this number was more than double among non-Hispanic Black women who experienced 37.1 maternal deaths per 100 000 live births. More than half of these deaths and near deaths were from preventable causes, with cardiovascular disease being the leading one. In an effort to amplify the magnitude of this epidemic in the United States that disproportionately plagues Black women, on June 13, 2020, the Association of Black Cardiologists hosted the Black Maternal Heart Health Roundtable-a collaborative task force to tackle the maternal health crisis in the Black community. The roundtable brought together diverse stakeholders and champions of maternal health equity to discuss how innovative ideas, solutions and opportunities could be implemented, while exploring additional ways attendees could address maternal health concerns within the health care system. The discussions were intended to lead the charge in reducing maternal morbidity and mortality through advocacy, education, research, and collaborative efforts. The goal of this roundtable was to identify current barriers at the community, patient, and clinician level and expand on the efforts required to coordinate an effective approach to reducing these statistics in the highest risk populations. Collectively, preventable maternal mortality can result from or reflect violations of a variety of human rights-the right to life, the right to freedom from discrimination, and the right to the highest attainable standard of health. This is the first comprehensive statement on this important topic. This position paper will generate further research in disparities of care and promote the interest of others to pursue strategies to mitigate maternal mortality.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales.

BACKGROUND: Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. METHODS: Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. RESULTS: From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. CONCLUSIONS: BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

INTRODUCTION: Les études sur les inégalités raciales en matière de soins aux patients admis en raison d'un arrêt cardiaque hors de l'hôpital (ACHO) dans le cadre d'un infarctus aigu du myocarde (IAM) ont montré des résultats contradictoires. On ignore si ces différences en matière de soins existent dans le système de soins de santé universel de l'Angleterre. MÉTHODES: Les patients admis en raison d'un diagnostic d'IAM et d'ACHO entre 2010 et 2017 du Myocardial Ischaemia National Audit Project (MINAP) ont fait l'objet de l'étude. Nous avons réparti tous les patients selon l'origine ethnique dans le groupe BAME (de l'anglais Black, Asian and minority ethnic, c.-à-d. Noirs, Asiatiques ou d'une minorité ethnique) vs le groupe des Blancs. Nous avons utilisé les modèles multivariés de régression logistique pour évaluer les prédicteurs des résultats cliniques et la stratégie de traitement. RÉSULTATS: Parmi les 14 287 patients admis en raison d'un IAM compliqué par l'ACHO, les patients du BAME constituaient une minorité de patients (1 185 [8,3 %]) par rapport au groupe des Blancs (13 102 [91,7 %]). Les patients du groupe BAME étaient plus jeunes (âge médian [écart interquartile]), 58 [50-70] ans que le groupe des Blancs, 65 [55-74] ans). Le choc cardiogénique (groupe BAME, 33 %; groupe des Blancs, 20,7 %; P < 0,001) et l'insuffisance ventriculaire gauche grave (groupe BAME, 21 %; groupe des Blancs, 16,5 %; P < 0,003) étaient plus fréquents au sein des patients du BAME. Il était plus probable que les patients du BAME soient vus par un cardiologue (groupe du BAME, 95,9 %; groupe des Blancs, 92,5 %; P < 0,001) et qu'ils passent une angiographie coronarienne que le groupe des Blancs (ratio d'incidence approché [RIA] 1,5, intervalle de confiance [IC] à 95 % 1,2-1,88). Le groupe BAME avait une mortalité intrahospitalière (RIA 1,26, IC à 95 % 1,04-1,52) et une récidive d'infarctus (RIA 1,52, IC à 95 % 1,06-2,18) plus élevées que le groupe des Blancs. CONCLUSIONS: Il était plus probable que les patients du BAME soient vus par un cardiologue et qu'ils passent une angiographie coronarienne que les patients blancs. Malgré cette différence, la mortalité intrahospitalière des patients du BAME, particulièrement de la population asiatique, était significativement plus élevée.

The role of imaging in women with ischemic heart disease.

Substantial advances and insights in medical technology and treatment strategies, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, ischemic heart disease (IHD) remains the leading cause of cardiovascular morbidity and mortality of women in the Western world. Advances in cardiovascular imaging, over the past 4 decades, have significantly improved the evaluation and management of the full spectrum of coronary atherosclerosis, which contributes to ischemic heart disease. The development of contemporary and novel diagnostic imaging techniques and tools have assumed an expanded role in the evaluation of symptomatic women to detect not only flow-limiting epicardial coronary stenosis and nonobstructive atherosclerosis, but also ischemia resulting from microvascular dysfunction. IHD is now diagnosed early and with greater accuracy, leading to improved risk assessment and timely therapies in women. In this article, we review the available evidence on the role of contemporary diagnostic imaging techniques in the evaluation of women with suspected IHD.

Spontaneous coronary artery dissection (SCAD): The underdiagnosed cardiac condition that plagues women.

Coronary heart disease (CHD) continues to be understudied, underdiagnosed, and undertreated in women. Gender and age bias complicate the evaluation of women with acute coronary syndrome (ACS). As a result, conditions like spontaneous coronary artery dissection (SCAD) are often missed. SCAD is an infrequent yet important cause of myocardial infarction (MI) with a predilection for young to middle aged women. The condition is thought to be under-reported, likely a result of both low index of suspicion as well as an unfamiliarity with SCAD's angiographic variants. Recently, the European Society of Cardiology (ESC) detailed an assessment pathway for patients with myocardial infarction with non-obstructive coronary arteries (MINOCA), a subset of which includes patients with SCAD. The pathway highlights the role of cardiac magnetic resonance (CMR) in addition to intracoronary imaging for increased diagnostic yield. Early and proper diagnosis is crucial in SCAD given the potential for sudden cardiac death, as well as the increased risk for future cardiac events including recurrent dissection. In addition, SCAD has frequently been associated with underlying connective tissue disease and/or arteriopathy, most commonly fibromuscular dysplasia (FMD), which requires careful screening. The lack of consensus on investigation or treatment highlights the need for increased awareness and further research to better understand this challenging entity.

FDA labeling of NSAIDs: Review of nonsteroidal anti-inflammatory drugs in cardiovascular disease.

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been extensively used worldwide for both chronic and acute musculoskeletal and inflammatory conditions. Extensive evidence has linked NSAID use with adverse cardiovascular events. This review article aims to review the existing evidence on the risk of cardiovascular and coronary events in both selective and nonselective NSAIDs, the time course of NSAIDs associated with cardiovascular risk, and specific populations that may be at increased risk.