Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA

Unfortunately, the data released in the JACC report are not new, but confirm the longstanding unfortunate and unacceptable disparities in CV morbidity and mortality across race/ethnicity that we see in the United States. The white/Black mortality gap was described 20 years ago by the Institute of Medicine and has been persistent, mainly driven by CVD.

What is the solution? It will not be easy. Limited access to therapy and adverse social determinants of health — where people work, live, play and pray — have a profound impact on CVD. New risk calculators are now attempting to integrate, based on ZIP code analyses, the social determinants of health and CVD burden.

We also have intrinsic inequality in the health care delivery system. Persons with no or limited insurance often don’t seek care until later stages of the disease process. At that time, increased obesity, physical inactivity, cigarette use and, most importantly — especially in the Black population — uncontrolled hypertension, manifest themselves in end-organ damage, including heart attacks, cerebrovascular accidents, HF and chronic kidney disease. We have known extensively for years that the poor control of these CV risk factors, complicated by the inherent inequalities of the health care delivery system, leads to worse outcomes at a higher cost. Although the United States, compared with other industrialized, Westernized societies, and also Japan, spends more per dollar per capita on health care, our health care spending has not translated to improved life expectancy. In fact, the life expectancy in the United States is shorter than that seen in comparable Westernized industrialized societies.

We know that race is a social construct, despite nuances of how disease presents, such as higher lipoprotein(a) in persons of African and South Asian descent, or forms of cardiomyopathy such as transthyretin-mediated amyloidosis (ATTR-CM). Nevertheless, the overwhelming reason for these disparate rates in CV morbidity and mortality are structural inequities — the social determinants and, unfortunately, intrinsic bias on how we as clinicians treat patients. The data are important to report, but simply reporting this important, persistent inequity will not solve the problem. We need to ensure that all patients are treated equally, regardless of race/ethnicity, sex/gender, socioeconomic status, geography, disability or ability. If we do not do this, we will not have an equitable society.

As I wrote in an editorial in 2022 (Ferdinand KC. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2022.10.007), if we want to tackle the elevated atherosclerotic CVD risk in the Black American population, we should maximize our understanding of social determinants of health, address uncontrolled major risk factors, employ coronary artery calcium scoring in patients at intermediate risk and identify patients with elevated Lp(a), while minimizing skin color or self-identified race, unmeasured genetic factors, low HDL as a marker of increased risk and high HDL and low triglycerides as markers of decreased risk.

The NIH and NHLBI have been attempting to address whether community interventions would be a step forward in reducing disparities in CV morbidity and mortality. We know of the powerful effects of the Los Angeles Black barbershop study conducted by the late Ronald G. Victor, MD (Victor RG, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1717250). There are now efforts to see if using community health workers and nurse practitioners to advance health practices in community and nontraditional settings can help patients control risk factors and stem the tide of end-stage disease where patients present to EDs at major institutions with the need for dialysis, admission for HF, treatment for acute stroke or interventions for acute MI. It has not yet been proven that this will be effective, but community-based interventions is one hopeful step forward.

Universal health care is a necessity. Health care is a right. If we don’t give access to excellent evidence-based care for all patients, we will pay the price with admissions and readmissions for what is largely preventable in terms of CVD.

Educating youth about health-seeking behavior, including avoiding excess sodium, saturated fat and processed foods, will also go a long way. The late Gerald S. Berenson, MD, showed in the Bogalusa Heart Study decades ago that atherosclerosis, including conventional risk factors such as dysglycemia, obesity and hypertension, are not simple manifestations of adulthood, but start in the adolescent and preteen years. We need to invigorate efforts to help our children understand the benefits of healthy lifestyle and the need to seek medical care early in disease processes, and not wait until manifestations of symptoms of disability.

We as clinicians cannot be passive and stand by. We all pay for this excess cost in terms of medical care, treating patients with end-stage renal disease at a cost of $90,000 to $120,000 per year, which is three times more in the Black population than predicted by population alone. Or treating patients with premature HF and recurrent admissions for HF. Or treating patients with stroke, the most chronic, costly cause of disability in the United States, again disparate in the Black population and mainly driven by poorly controlled hypertension.

We know what to do. Now the challenge is to implement what we know.