Findings from a new Northwestern Medicine study rebut the idea that Black individuals’ higher risk of cardiovascular disease is because of biological differences.
“The key take-home message is that racial differences in cardiovascular disease are not due to race itself, which is a social concept that is not related to biology.”
Black adults are at significantly higher risk (1.6-2.4 times) for cardiovascular disease than white adults. The new study found these large differences can be explained by differences in social determinants of health (like education or neighborhood-level poverty), clinical factors (like blood pressure) and lifestyle behaviors (like dietary quality).
“The key take-home message is that racial differences in cardiovascular disease are not due to race itself, which is a social concept that is not related to biology,” said corresponding author Dr. Nilay Shah, assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician. “Rather, these differences in cardiovascular disease can be explained by differences in social and clinical factors. Clinicians should be evaluating the social determinants that may be influencing the health of their patients.
“The data from this study starts to identify what contributes to the higher burden of heart disease experienced by Black adults, and how much each factor matters.”
Black women had a 2.4-times higher risk for cardiovascular disease compared with white women. The study found that clinical factors, neighborhood-level factors and socioeconomic factors explained the largest components of the higher risk experienced by Black women.
Black men had a 1.6-times higher risk for cardiovascular disease compared with white men. The study found that clinical factors, socioeconomic factors and lifestyle behaviors explained the largest components of the higher risk experienced by Black men.
“The findings of significantly higher risk in non-Hispanic Black adults compared with non-Hispanic white adults is not surprising—this is well-known,” said senior author Dr. Sadiya Khan, assistant professor of cardiology and epidemiology at Feinberg and a Northwestern Medicine physician. “But it was surprising that the risk for cardiovascular disease was the same once social and clinical factors were considered over time. This finding is really important to rebut that there is an unexplained or genetic reason that Black individuals have higher risk.”
The study’s findings are important because they show that disparities in heart disease experienced by Black adults could be reduced by improving preventive care of heart disease risk factors and addressing social determinants, Shah said. The data provide a guide to identify strategies that may be particularly effective at reducing the persistent differences and disparities in heart disease that exist in the U.S.
“It is important to note that clinical risk factors, lifestyle and depression are not independent of socioeconomic status and neighborhood segregation,” Khan said. “Future research needs to go upstream to target social determinants of cardiovascular health. Our study lays groundwork to help inform community-engaged interventions that ensure equal opportunities for all people to have access to high-quality foods, environments and health care.”
The study evaluated data from about 5,100 Black and white adults who participated in the CARDIA (Coronary Artery Risk Development in Young Adults) Study at four locations in the U.S. (Chicago; Minneapolis, Minn.; Oakland, Calif.; and Birmingham, Ala.). The participants enrolled around 1985 and have been followed for over 30 years. The scientists evaluated the information participants provided starting from the time of their enrollment to determine the role of social and clinical factors in the differences in cardiovascular disease experienced by Black compared with white adults over the course of 30 years of follow-up.
Other Northwestern co-authors include Norrina Allen, Dr. Donald Lloyd-Jones, Mercedes Carnethon, Kiarri Kershaw, Lucia Petito and Hongyan Ning.
Funding for the study was provided by the National Heart, Lung, and Blood Institute (NHLBI) (grant K23HL157766); the National Institutes of Health (grants P30AG059988 and P30DK092939); and the American Heart Association (grant 19TPA34890060). The CARDIA study is conducted and supported by the NHLBI in collaboration with the University of Alabama at Birmingham (grants HHSN268201800005I and HHSN268201800007I), Northwestern University (grant HHSN268201800003I), University of Minnesota (grant HHSN268201800006I) and Kaiser Foundation Research Institute (grant HHSN268201800004I).
Nurses can go into so many different areas in the field, cardiovascular nursing being just one of them. But as with all career choices, nurses need to have the right information to determine if this area is right for them.
We interviewed Jill Price, PhD, MSN, RN, senior director of Chamberlain University’s College of Nursing Post-Licensure programs. Price has nearly two decades of experience in Critical Care and Cardiovascular Nursing, and trained nurses at the first cardiac care center in the U.S. Virgin Islands—St. Croix—in critical care and cardiovascular care. Previously, Price worked as an advanced cardiac life support instructor and pediatric advance life support instructor.
What are the different types of nurses used in cardiovascular care? What do their jobs entail?
For nurses who don’t have any sort of critical care experience and want to go into cardiovascular nursing, I would first recommend the nurse seek out a critical care training course and then either a job in a critical care step down unit or an intensive care unit. Some hospitals require a year of medical-surgical nursing experience first before seeking a position in a critical care unit, so the nurse would need to check with the institution on what their requirements entail.
The different types of nurses who pursue cardiovascular care are those who love taking care of very sick patients with several comorbidities. These nurses are a unique group in that they like to help patients with complex medical problems, often times requiring advanced technology to maintain their heart rate. Cardiovascular nurses have advanced critical thinking skills.
If nurses want to pursue a job in cardiovascular care, what additional training or certifications do they need?
In terms of certification, I would recommend getting certified as a critical care nurse with the American Association of Critical-Care Nurses (AACN) organization. Additionally, they should seek out advanced cardiac life support (ACLS) and advanced pediatric life support (PALS) certifications.
What are the biggest challenges of being a cardiovascular nurse?
Since cardiovascular disease—which includes heart attacks—is the leading cause of death in the United States, nurses working in cardiovascular care, inclusive of interventional cardiovascular laboratories, are on call often. This requires not only working during the week at normal scheduled hours, but also being on call after normal working hours. And when a nurse is called in, they have less than 30 minutes to drop whatever they are doing to get to the hospital and save a patient’s life. Cardiovascular nurses are dedicated and committed to their job and time away from families can be challenging for some.
What are the greatest rewards?
Resuscitating a patient back from being in full blown cardiac arrest and seeing them walk out of the hospital like they were never sick. Or witnessing a patient whose limb was blue from an arterial vascular occlusion and working to open the occlusion and save the person’s limb by witnessing the blood flow restoration in the limb.
What were some of the most important things you learned while doing that kind of work?
I learned that with new devices and drugs consistently being developed, the cardiovascular nurse must stay abreast on all the latest technology and innovation in order to advocate for the patients’ best interests and choice in health care. Also, timing is everything, from saving the heart to the brain. You have to essentially dedicate your life to this kind of nursing, and even if you make a difference in one person’s life—but there will be many—you will feel proud knowing all that dedication and rushing to their care was worth it.
If nurses are interested in becoming a cardiovascular nurse, what advice would you give them?
Be prepared to devote time away from your family in return for helping save lives. Work in telemetry or acute care settings right out of nursing school and enroll in a critical care course, with the goal of becoming a certified critical care nurse, as soon as possible.
With advance research always being conducted on how to help decrease, prevent, and treat cardiovascular disease, you will get to learn something new every day.
Of all the risk factors for heart disease, the areas you have no control over are often the ones that are especially troublesome. While you can make inroads to a healthier diet, more activity and exercise, reducing stress, and even taking appropriate medications, it often feels like there’s nothing you can do to change your family’s track record of heart disease.
As February is American Heart Month, now is a great time to take stock of your own heart health. Knowing that your family carries a higher risk for heart disease is actually a great motivator to keep your own heart as healthy as possible. In many cases, if you ramp up your efforts to control what you can, you can negate some of your family’s health lineage.
Can you change your family’s past? No – if you had a father and three aunts who died from heart disease in their 40s, you need to take that very seriously. But it doesn’t mean you will take the same path.
How can you beat your genetics?
Know Your History
The American Heart Association recommends gathering as much family history as you possibly can. If you are at least able to start with members of your immediate family, that will help you assess your risk.
Look for family members with a history of heart attacks, strokes, high blood pressure, high cholesterol, or congestive heart failure. Find out how old family members were when they were diagnosed and how old they were if they died from the disease. And try to notice any patterns – is the predominant problem heart attack or stroke?
Accept (But Don’t Give Into) Your Genes
There is virtually no way to change your genetic makeup. But if you carry an elevated risk, it can make you feel unsure of what’s to come. So while you can’t change your genetic cards, you can change how you live your life.
A lifestyle that is heart-healthy, heart-friendly, and heart-supportive can contribute greatly to your overall heart health and start to bring your elevated risk into a more normal range.
Talk with Your Team
Talk to your healthcare providers to make sure you are getting all the tests you need to uncover any early indicators of heart disease. Discuss medications and other therapies that can lower your blood pressure and your cholesterol and even get things like triglycerides into normal range.
Some minority populations are more predisposed to heart disease (including African Americans and Hispanics), so go over some of those risk factors. And have a discussion about any other conditions you may have that could put you at a higher risk including diabetes, depression, and even psoriatic arthritis.
Make Heart Health a Priority
No one else is going to put your heart health first, so that’s going to be up to you. Put caring for your heart at the top of your to-do list. That means taking a look at obvious things like your eating habits, your weight, your blood pressure and cholesterol numbers. But it also means making sure you get enough sleep (lack of sleep raises your risk of heart disease over time) and making sure you take the time for pleasure.
Loneliness also contributes to declining heart health, so develop a rich social life and figure out exactly what that looks like for you. Some people want three parties every weekend and others are happiest having dinner with best friends every couple of weeks or a favorite book club every week.
No matter what story your family health patterns reveal, it doesn’t mean that’s your destiny. With some changes and lots of diligence and close observation, you can keep you heart healthy and strong.
From 2012 to 2015, Jo-Ann Eastwood, associate professor at UCLA School of Nursing, partnered with several local African American churches to conduct an American Heart Association–funded clinical trial that tested the effectiveness of using smartphone apps to help black women ages 25–45 reduce their risk for heart disease. Most of the study participants had multiple risk factors, such as obesity, hypertension, high cholesterol, high stress levels, and a family history of cardiovascular disease.
First, Eastwood and her team taught four weekly education sessions to increase the young women’s awareness of their risks and provide tips for making risk-lowering lifestyle changes. For many participants, the classes—which covered topics such as knowing your family history, heart-healthy eating, getting more exercise, and techniques for coping with stress—were an eye-opening experience.
After the last class, everyone in the intervention group was given a smartphone uploaded with apps Eastwood had developed in collaboration with UCLA’s Wireless Health Institute. “We used the apps to stay connected with the women,” she says. “They couldn’t call out on the phones, but we could call them and send them text messages.”
The apps were programmed to send a rotating series of daily reminders, such as “How many servings of vegetables did you eat today?” and “Did you try to reduce your stress today?” The women entered their answers into the phone, which streamed the data to the researchers through a server at the university.
In addition, the phones automatically tracked the women’s physical activity throughout the day and took their blood pressure once a week. “We gave them wireless talking blood pressure machines,” Eastwood explains. “The women would push a button on the phone, their blood pressure would be taken, and the phone would tell them what their numbers were. Then they would push a button that would stream it to our server.”
Although Eastwood is still analyzing the study’s results, her initial findings are impressive. After six months, compared with a control group, the women who received the smartphone intervention had lowered their blood pressure and total cholesterol, increased their HDL (“good”) cholesterol, reduced their waist circumference, and decreased their stress. “They were changing their diets, they were becoming more physically active, and they made notable and significant lifestyle changes over time,” Eastwood reports.
Even more encouraging, these changes empowered the women to improve not just their own cardiovascular health but their families’ as well. One woman, for instance, had been serving her husband and children meals that were high in sodium, fat, and cholesterol. As a result, her husband’s blood pressure was 210/120—dangerously out of control. But when she switched to more heart-healthy cooking habits, his hypertension began to drop dramatically. And at the end of the study, says Eastwood, “he came in and thanked us for saving his life, because his blood pressure was now 120/80 for the first time since sixth grade.”
The first national study on Hispanic health risks and leading causes of death in the United States by the Centers for Disease Control and Prevention (CDC) showed that similar to non-Hispanic whites (whites), the two leading causes of death in Hispanics are heart disease and cancer. Fewer Hispanics than whites die from the 10 leading causes of death, but Hispanics had higher death rates than whites from diabetes and chronic liver disease and cirrhosis. They have similar death rates from kidney diseases, according to the new Vital Signs.
Health risk can vary by Hispanic subgroup. For example, nearly 66% more Puerto Ricans smoke than Mexicans. Health risk also varies partly by whether Hispanics were born in the United States or in another country. Hispanics are almost three times as likely to be uninsured as whites. Hispanics in the United States are on average nearly 15 years younger than whites, so taking steps now to prevent disease could mean longer, healthier lives for Hispanics.
“Four out of 10 Hispanics die of heart disease or cancer. By not smoking and staying physically active, such as walking briskly for 30 minutes a day, Hispanics can reduce their risk for these chronic diseases and others such as diabetes,” says CDC Director Tom Frieden, MD, MPH. “Health professionals can help Hispanics protect their health by learning about their specific risk factors and addressing barriers to care.”
This Vital Signs report recommends that doctors, nurses, and other health professionals
• work with interpreters to eliminate language barriers when patients prefer to speak Spanish.
• counsel patients with or at high risk for high blood pressure, diabetes, or cancer on weight control and diet.
• ask patients if they smoke and, if they do, help them quit.
• engage community health workers (promotores de salud) to educate and link people to free or low-cost services.
Hispanic and other Spanish-speaking doctors and clinicians, as well as community health workers or promotores de salud, play a key role in helping to provide culturally and linguistically appropriate outreach to Hispanic patients.
The Vital Signs report used recent national census and health surveillance data to determine differences between Hispanics and whites, and among Hispanic subgroups. Hispanics are the largest racial and ethnic minority group in the United States. Currently, nearly one in six people living in the United States (almost 57 million) is Hispanic, and this is projected to increase to nearly one in four (more than 85 million) by 2035.
Despite lower overall death rates, the study stressed that Hispanics may face challenges in getting the care needed to protect their health. Sociodemographic findings include:
• About one in three Hispanics have limited English proficiency.
• About one in four Hispanics live below the poverty line, compared with whites.
• About one in three has not completed high school.
These sociodemographic gaps are even wider for foreign-born Hispanics, but foreign-born Hispanics experience better health and fewer health risks than U.S.-born Hispanics for some key health indicators, such as cancer, heart disease, obesity, hypertension, and smoking, the report said.
The report also found different degrees of health risk among Hispanics by country of origin:
• Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites. Mexicans also are nearly twice as likely to die from chronic liver disease and cirrhosis as whites.
• Smoking overall among Hispanics (14%) is less common than among whites (24%), but is high among Puerto Rican males (26%) and Cuban males (22%).
• Colorectal cancer screening varies for Hispanics aged 50 to 75 years.
• About 40% of Cubans get screened (29% of men and 49% of women).
• About 58% of Puerto Ricans get screened (54% of men and 61% of women).
• Hispanics are as likely as whites to have high blood pressure. But Hispanic women with high blood pressure are twice as likely as Hispanic men to get it under control.
“This report reinforces the need to sustain strong community, public health, and health care linkages that support Hispanic health,” says CDC Associate Director for Minority Health and Health Equity, Leandris C. Liburd, PhD, MPH, MA.
