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AHA: Social factors could reverse trend of declining US deaths from heart disease, stroke
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Social determinants such as education, environment, income and race/ethnicity have the potential to reverse the trend of declining mortality from MI, stroke and other heart diseases in the United States, according to a new scientific statement from the American Heart Association.
“The steady decline of death from [CVD] that began in the 1970s might be coming to an end,” Edward P. Havranek, MD, FAHA, cardiologist at Denver Health Medical Center, professor of cardiology at the University of Colorado School of Medicine, Denver, and chair of the statement writing group, said in a press release. “Overall population health cannot improve if parts of the population do not benefit from improvements and treatment. Failure to address the social dynamic of [CVD] will compromise the [AHA’s] 2020 Impact Goal to improve [CV] health of all Americans by 20% while reducing deaths from [CVD] and stroke by 20%.”
Advances not shared by all
The prevalence of CVD in the U.S. is predicted to increase by 10% from 2010 to 2030, and the statement authors attributed that in part to “a dramatic rise over the past 25 years in obesity and the hypertension, diabetes and physical inactivity that accompany weight gain.” This, they wrote, may have been caused by “changes in societal and environmental conditions that have led to changes in diet and physical activity. At the same time, there is increasing awareness that the benefits of advances in prevention and treatment have not been shared equally across economic, racial and ethnic groups in the United States.”
Havranek and colleagues summarized the current knowledge on how social factors may influence CVD outcomes and suggested future directions for research.
Lower levels of education are associated with a greater chance of more CVD risk factors, higher risk for CV events and increased rates of CVD mortality. Lower education levels also appear to be associated with lower health literacy, which is itself linked with lower likelihood of receiving interventions to improve self-care behavior, risk factor control and CV outcomes, according to the statement.
Lower levels of income also appear to be associated with worse CVD outcomes, although not in as linear a fashion as that for lower levels of education, the authors wrote.
Numerous studies have documented racial discrepancies in U.S. CVD outcomes, Havranek and colleagues wrote. There is evidence of a link between reported racism and high BP or hypertension diagnosis, but “of great concern to society is that healthcare provider bias contributes to the problem,” they wrote. Research on that topic indicates that health care providers are unlikely to exhibit explicit bias but may exhibit implicit bias, including being more likely to incorporate stereotypical assumptions into their decisions and cultivating worse clinical interactions with black patients.
“The concepts of implicit bias and stereotype threat are real phenomena that affect health and disease and may be root causes of disparate care,” Havranek and colleagues wrote. “Effective interventions to improve patient-provider communication and patient satisfaction/trust across racial lines are clearly needed.”
There is a lot of evidence that the socioeconomic level of the neighborhood where a person lives contributes to his or her risk for heart disease, because of “diminished socioeconomic resources, access to healthy foods and resources for physical activity,” Havranek and colleagues wrote. “Proactive efforts to change the built environment may reduce the burden of CVD risk.”
Other social barriers to optimal CVD prevention and treatment include linguistic and cultural differences between patients and providers, and access to CVD and stroke care, according to the statement.
More research needed
The authors called for more research to examine the intergenerational transmission of social disadvantage and its link to CV health; epigenetic and other pathways that link socioeconomic factors with CV outcomes; linguistically and culturally appropriate care; complex interactions between CV health and social factors; and social determinants of health that can be broken down into modifiable risk factors. – by Erik Swain
Disclosure: Havranek reports no relevant financial disclosures. See the full statement for the relevant financial disclosures of the other authors and reviewers.
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