Heart Failure: Why Minorities Are at a Disadvantage

Welcome, everyone, to this roundtable discussion on heart failure. I'm Dr. John Whyte, the chief medical officer at WebMD. Six million Americans have heart failure. It's one of the most common reasons people are admitted to the hospital. And despite all the advances we have in testing and treatment, not everyone benefits from that.

What do I mean? Blacks are diagnosed at a much later stage and advanced disease compared to whites. When they do get treated, they often don't receive the same type of therapies, and they're often not treated by expert cardiologists compared to whites. It's a similar situation for Hispanics. But I'll tell you, we don't even have good data to truly know the extent.

And women? Guess what? Women of all races and ethnicities are also diagnosed later and at more advanced stages. What do we do about this? How do we address it?

To help unpack it all, I'm joined by two experts. Dr. Reginald Robinson is a cardiologist at MedStar Health, and he's the president of the Board of the Directors for the Eastern States region of the American Heart Association. And Dr. Abiodun Ishola, he's an interventional cardiologist at St. Elizabeth Health Care.

Doctors, thanks for joining me.

Thanks for having us.

Thanks for having us.

So Dr. Robinson, I want to ask you, why are we diagnosing heart failure so late in life? Typically 65 and 70 for people of color-- men of color, even, and women of color. And then they're at advanced stage.

What's going on here? What's the etiology? Is it that they're not coming to the doctor? They don't recognize the symptoms? The doctors are dismissing it, saying, you know, I'm not even going to check? What's the situation here?

There are multiple areas, and you hear these terms now that are coming to the forefront with health equity and the social determinants of health. Social determinants of health, or how people live, pray, celebrate in their environment. And we don't really think about how environment impacts outcome. We've been taught in medical school that ACE inhibitors or anything that ends in "-april"-- like enalapril, ramipril-- or an ARB or angiotensin receptor blocker that ends in "-sartan"-- like losartan-- they didn't work as well in African-Americans.

But we know that we're not a heterogeneous population. So if it's the standard of care, we shouldn't withhold standard of care from any treatment regimen. So again, we have to look at not only patients that come into the hospital, but how do we follow up some of these patients that zip code will dictate their outcome?

And I want to push you on this a little. Do we change treatment strategies based on a person's race, gender, ethnicity? Is there variability of drug response, meaning that certain populations will respond better to certain types of medications? Should there be a difference in treatment strategy?

Well, again, that's been the traditional treatment. Older studies looked at hydralazine and isosorbide. A small subset of population showed that an African-American population did better when we actually used and implemented that on top of traditional treatment. But again, if its standard of care, we still should use standard of care.

Why aren't they being offered it? We know that from the data.

Yes. A lot of issues. One, we may not even think to go through the insurance company. They're doing it less so now, but there tends to be a struggle when you order for a patient that has Medicare or Medicaid. You have to go through prior authorization sometimes to get those patients on it, where you may not have to do that in a traditional insurance carrier.

So I'm seeing it less and less, but it still has been an issue, and I guess we have to really push that. We have to push getting those standard of care treatment for patients, because we know that's best for them.

Dr. Ishola is an interventional cardiologist, so I won't push him on this question, but I'm going to push it back to you, if I may. You're saying social determinants of health-- how they pray, how they eat-- should I be asking patients, when I'm trying to manage heart failure, about food insecurity? Should I be asking them about their stress? Should I be asking them if they're depressed?

I'm a big fan-- or my philosophy is, you have to treat the whole person. You can't just treat the symptom. You can't just treat one facet of a person. To get good outcomes, you have to see the person as a whole and understand that it's critical to treat, also, the mindset and also the disease process itself. We know the lifestyle is a big factor when it comes to high blood pressure.

So you can give all the medications you want, for example. But when you have high salt intake, a very sedentary lifestyle, and mindset of not going to the doctor except when you're sick, all you're doing is really treating the disease and not the person. So I would definitely-- personally, I believe you can't isolate the patient and the mindset from the disease process to get a durable, lasting result, and that is what we've seen over time.

And we do understand that when patients feel like they can open up to their physician and the doctor actually cares about what is going on, they reveal to you things that they never talk about to other doctors, which is one of the major issues we've seen with disparity. When we have underrepresentation of minority doctors or female doctors, a lot of times people don't feel like the doctor necessarily understands them, and wouldn't open up about those social factors as limiting care or limiting a lifestyle issue. So it's a multifaceted issue, but definitely you have to focus on the whole person to get a durable outcome.

We've been talking about cardiovascular disease as the leading cause of death since the first pandemic, right? And why is that? Because we've been focusing on the peak of that pyramid-- how someone eats, their exercise level. But the base of the pyramid is actually something we really haven't covered-- how are those social determinants of health?

So if someone doesn't have access to transportation to get to their doctor's office, or they have to wait on metro access or some kind of delivery service to take them there. And when you look at studies showing hospitalization and readmission rates for African-Americans or Latino-Americans, the morbidity, or someone dying in the hospital, is probably smaller, but when you look at 30-day, 60-day, 100-day readmission rate, that tends to be a lot higher. You're going to see them back.

I want to turn to the Hispanic population. We often don't have good data about that. In terms of when we collect data, that's often a missing data point, about ethnicity. What exactly do we know about the prevalence of heart failure in Hispanic populations? Dr. Robinson?

It was interesting. In this study, they looked at a population of Hispanic patients, and it's harder to do that because they're not a heterogeneous group. You might see some from immigrants from El Salvador different than if we lump them in with someone from Spain or Cuba or Mexico-- the same thing we see in the African-American population, where, when they look at white population, the people that lived in the non-distressed populations versus the distressed, there was a huge variable. And you had to take in people living in urban environments versus rural environments access to care.

So we do know that there a non-heterogeneous group in the Hispanic population, and looking at those factors and including those is important to really trying to tease through the data.

And we need to collect more data in terms of different ethnicities in general, not just Hispanics. Doctor Ishola, what about the presentation of heart failure in women? Is it different than it is in men, similar as heart attacks are different-- sometimes more subtle? How do women typically present with heart failure?

Yeah, kind of like in coronary disease, women tend to present a lot different. Part of the issue is the lack of awareness sometimes as well. You know, people present with shortness of breath, palpitations, fatigue, a decline in functional status, and sometimes those symptoms have been masked as something else-- maybe panic attacks and anxiety attacks-- and overlooked for a while. A lot of studies have shown, recently, women and Blacks and people of lower socioeconomic status tend to be diagnosed in emergency rooms than their white counterparts, male counterparts, which tells us those symptoms are being overlooked for multiple reasons.

We do know that in coronary disease, the estrogen protective effects delays the diagnosis of CAD or gives them protection until they're in their 60s. So we do understand that most women don't develop significant heart failure till their 50s and 60s because there's less prevalence of coronary disease.

10 years later, typically, than men, in general.

Exactly. Exactly. The second issue is a lot of women, when they develop heart failure, tend to develop more diastolic heart failure than women, especially in their 60s and 70s, than systolic heart failure. And also, the knowledge base of treating that is variable from place to place. And I think that has played a factor as well. The last issue is the mortality factor as well.

Even though women don't die as much compared to men, they have significant morbidity and re-hospitalization. So I think there's a lot of those factors playing a role. One is atypical presentation, just like in coronary disease. And two is the late diagnosis for the facts that we've talked about.

Gentlemen, let's talk about solutions, right? So we know there's disparate care. How do we help eliminate disparities when we're addressing heart failure in people of color and women?

Well, we just celebrated Martin Luther King celebration, and one of his biggest things-- he said that health care is one of the biggest issues when you look at disparities, when you look at overall outcomes.

The greatest disparity is health.

REGINALD ROBINSON: And without a healthy workforce, without a healthy population, you can't move the needle forward. So like we're having this discussion with physicians on this chat, we need to have politicians on the chat, we need to have faith-based organizations on the chat, we need to have people that are actually on the ground doing things within the community. Because, again, physicians, we've been doing this for over 100 years, over a century mark. The Heart Association is almost 100 years old in 2024, and we've been discussing this.

But we need to bring legislators in to look at those social-- how social determinants impact health. Otherwise we'll continue to look at this.

Dr. Ishola, the final word.

I would say the way forward is to realize we've kind of talked about as the socioeconomic factors play as much as a role in preventing recurrence as much as the disease process itself. And there is really no way to untie those two processes. They're very interlinked.

So to really make progress when it comes to heart disease, we have to focus on the social and economic factors playing a major role in the prevalence of what we see today.

Doctors, I want to thank you both for raising awareness, for helping us to think through what are the strategies and solutions to creating more equity in the treatment of heart failure.

Thank you.

Thank you for having us.

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