By Angela Ryan Lee, MD 

Published on March 16, 2022

 Medically reviewed by Jeffrey S. Lander, MD

Cardiovascular disease (CVD), also known as heart disease, is the leading cause of death worldwide.¹ CVD includes conditions such as hypertension, stroke, peripheral artery disease, and more.

Prevention is an important strategy to reduce death and suffering from CVD. It relies on managing risk factors and starting preventive medications for those with elevated risk. Yet, inequities exist in CVD rates, risk factors, treatment, and prevention.

This article discusses risk factors for CVD, health disparities, prevention strategies, and ways to advocate for treatment.

Jochen Tack / Getty Images

Disparities in Cardiovascular Disease

Heart disease does not affect all groups equally. Race and ethnicity, gender, geography, genetics, and socioeconomic status have all been associated with variable outcomes.

Communities that often experience barriers to care that lead to worse health outcomes include:²

• Black and Brown people

• People with lower socioeconomic status

• People with lower education levels

The reasons for this are complex, with many contributing factors.

Race and Ethnicity

Race and ethnicity are socially constructed labels based on ancestral and cultural characteristics. While some genetic factors are linked to ancestry, science makes it clear that race is not biological.

When considering how race and ethnicity relate to CVD, it's important to note that many of the differences are not due to genetic predisposition, but to environmental conditions known social determinants of health. These include things factors like:³

• Education

• Financial stability

• Access to health care

• Social stigma and discrimination

• Neighborhood and community factors

While social determinants of health increase CVD rates through an increase of risk factors, they are not the only cause of racial disparities in CVD. Access to healthcare, biases within the healthcare community, and the ways bias within health care have broken community trust in the system also contribute.

Some examples of these outcomes include:

• In the United States, Black adults have the highest rates and highest mortality from CVD. According to data from the Centers for Disease Control and Prevention (CDC), CVD mortality rates of non-Hispanic Black Americans are double that of non-Hispanic Asian or Pacific Islander.⁴

• Black Americans have the highest rates of peripheral artery disease (PAD), a condition in which atherosclerosis affects blood supply to the lower extremities. Incidence of PAD in Black Americans is double that of White Americans.⁵ Furthermore, compared to White Americans, Black Americans more often undergo amputation instead of procedures to open up the artery, even after correcting for socioeconomic status.⁶

• Evidence suggests that certain minority communities receive worse care for CVD. For example, Black and Latino people presenting with stroke were less likely to receive certain treatments compared to White patients.⁷

• People of South Asian heritage living in the United States have increased rates of atherosclerosis and worse outcomes with hospitalization and death than other groups.⁸

Gender

Gender discrepancies in CVD are also prevalent. CVD is the leading cause of death regardless of gender, but differences in diagnosis and treatment contribute to variable outcomes.

• While mortality rates for CVD have declined over the past few decades, cisgender women have seen less of a decline than cisgender men.⁹

• One study showed that in prehospital care for chest pain and cardiac arrest, cisgender women less often received recommended aspirin, and were less often transported with lights and sirens in the ambulance.¹⁰

• Another study showed that one year after hospitalization for heart attack, cisgender women were less likely than cisgender men to be on appropriate medications. This was attributed to not being prescribed the appropriate treatments, rather than self-discontinuing treatment.¹¹

• Members of the transgender community may experience higher rates of CVD and mortality, as longstanding evidence links social discrimination and stigmatization, which trans people experience, to poor CVD outcomes. While studies show transgender people undergoing hormone therapy have higher incidence of heart attacks, evidence of a direct relationship between higher heart attack incidence and undergoing hormone therapy remains inconclusive.¹²¹³

Geography

Within the United States, disparities also exist based on geography. These disparities can be regionally-based, or exist based on rural vs. urban environments. For example:

• Residents of rural areas experience higher death rates from CVD, partly due to reduced access to healthcare.¹⁴

• Southern states have the highest rates of CVD and CVD-related mortality.¹⁵

Socioeconomic Status

Socioeconomic status, which includes income, education, employment, and environmental factors, is a major driver of CVD incidence and outcomes.

• Studies have shown an association with lower levels of income, lower education levels, and unemployment with CVD and mortality.¹⁶

• Worldwide, low- and middle-income countries account for 3 in 4 deaths from CVD.¹⁷

Disparities in CVD Risk Factors

Health disparities also exist for individual CVD risk factors. Those belonging to groups that are widely discriminated against and socially stigmatized may be more likely to have a particular risk factor, be affected at a younger age, and diagnosed later in the course of disease.

High Blood Pressure

Hypertension, or high blood pressure, is one of the leading risk factors for CVD, and affects some groups more than others.

• Non-Hispanic Black Americans have the highest rates of hypertension and are less likely than White adults to have their blood pressure adequately controlled.¹⁸

• Low socioeconomic status is associated with higher rates and worse control of hypertension.¹⁹

• Rates of hypertension are highest in the southeastern U.S.²⁰

Diabetes

Diabetes is another common risk factor for CVD. Rates of diabetes and level of blood sugar control are worse in certain groups.

• Diabetes is most common in people of American Indian/Alaskan Native origin, who have nearly double the rates of diabetes compared to White Americans. Non-Hispanic Black and Hispanic-Latino Americans also have higher rates of diabetes.²¹

• Those with lower education levels have higher rates of diabetes and are less likely to receive recommended preventive care, like eye and foot exams.²²

• People living in the southeastern U.S. have higher rates of diabetes.²²

High Cholesterol

High cholesterol is a major CVD risk factor that affects groups unequally. Furthermore, some groups are less likely to receive appropriate therapies to control cholesterol numbers.

• People of South Asian descent have a higher incidence of high cholesterol, which contributes to their increased risk of and earlier onset of atherosclerosis.²³

• Studies suggest that therapies given to cisgender women are less aggressive than those given to cisgender men. This is also the case for Black Americans compared to White Americans. Black cisgender women were 19% less likely to be treated for high cholesterol compared to White cisgender men.²⁴

Smoking

People belonging to socially stigmatized groups and those with lower income, education, and socioeconomic status have higher tobacco-related risk.

• Those with lower income and lower education have higher smoking rates.²⁵

• People who identify as LGBTQ+ have higher smoking rates than those identifying as cisgender and heterosexual.²⁶

• Secondhand smoke exposure is highest for Black Americans than any other racial or ethnic group.²⁷

• Smoking cessation rates are lower for those with lower education and those in urban areas.²⁸

Other Risk Factors

Other CVD risk factors with disparities in prevalence and treatment across minority groups and geographic location include:

• Chronic kidney disease

• Excessively overweight

• Nutrition

• Sedentary lifestyle

Disparities in CVD Prevention

To add to the inequities in CVD and its risk factors, prevention of CVD has its own share of problems. The following are just some of the issues that contribute.

• The ASCVD risk calculator, which the American Heart Association and the American College of Cardiology guidelines recommend for estimating ASCVD risk, doesn't accurately convey risk in Hispanic and Asian populations.²⁹

• Black adults who meet recommendations for starting statins are less likely to have them prescribed.³⁰

• Research on transgender people, CVD outcomes, and CVD prevention remains limited.

• Cisgender women who meet recommendations for starting statin therapy are less likely to have them prescribed, or have adequate doses prescribed.³¹

• Studies suggest that people of East Asian descent have more adverse effects from statins.³²

Contributing Factors

Social determinants of health account for many of the disparities of CVD, risk factors, and prevention. They include the following:

• Access to health care

• Insurance status and ability to afford medications

• Language barriers

• Health literacy

• Nutrition status (access and ability to afford nutritious food choices)

• Cultural diet preferences

• Ability to exercise, including a safe space for exercise

• Stress, including chronic stress related to all forms of systemic oppression

In addition, systemic factors, such as biases within the healthcare system, contribute to inequalities. For example, many clinical studies were done on White men, leaving out Black, Brown, and gender oppressed people.

Further, members of some socially stigmatized groups distrust the healthcare system. This is in part due to historic and current racist, sexist, cisgender normative, and heteronormative practices.

The Tuskegee Syphilis Study

One example of historic racism in medicine is the unethical Tuskegee syphilis study that took place in 1932. In the study, Black patients were deliberately not treated for syphilis in order to study its long-term effects.³³ There are many other studies that suggest ongoing racism and biases in medical practice, with certain groups receiving less effective care.

What Can Be Done?

While advancements in treatment and prevention of CVD have come a long way in the last several decades, it's disheartening that such significant disparities still exist. Fortunately, the scientific community is more aware of health disparities. More research is being done on this topic, with goals being set to improve healthcare equity.³⁴

While large-scale change is needed to improve health equity, it's also important that each individual is empowered to be an advocate for their own health.

The first step of CVD prevention is awareness of increased risk. Next steps involve specific actions, which can include personalized lifestyle changes, understanding the role of prescribed medication, and conversations with the healthcare team.

Lifestyle Factors

Certain risk factors for CVD are called "modifiable," because they are able to be changed by individual behaviors. These include:

• Sedentary lifestyle

• Smoking

• Diet high in saturated and trans fats, sodium, processed foods, and sugar

Other modifiable risk factors can be improved with both individual behaviors and medical therapy, like diabetes, high blood pressure, and high cholesterol.

For modifiable risk factors, some measures can be taken to help reduce a person's risk of developing CVD:

• Exercise: While not everyone has the same ability to exercise, getting some form of exercise for those who are able has immense heart health benefits. If you have angina or have had a heart attack, you may benefit from cardiac rehabilitation, which is a structured program that incorporates exercise, counseling, and education.³⁵ Ask a healthcare provider for more information or a referral, if possible.

• Diet: A heart-healthy diet (like the Mediterranean diet) includes a high intake of vegetables, fruits, whole grains, nuts, and beans, and is low in processed foods, sweetened beverages, salt, and saturated and trans fats. Unfortunately fast food, which has trans fats and is loaded with salt, is cheaper than healthier options. Finding and affording fresh fruits and vegetables may not be possible. Canned or frozen fruits and vegetables are a more affordable alternative, and can be just as healthy (just watch out for sugar and sodium content). Beans are an inexpensive, accessible healthy protein source. Replacing sweetened beverages with water is another healthy step.

• Stress: Stress is another contributor to CVD. Stress management can improve quality of life. Affordable ways to relieve stress include meditation, breathing exercises, journaling, exercise, time in nature, and connection with others.

Medications

After lifestyle changes, the cornerstone of CVD prevention is statin therapy.

Guidelines from the American College of Cardiology and the American Heart Association recommend calculating a risk score, called ASCVD Risk Estimator, which assigns a 10-year and lifetime risk of ASCVD.³⁶

When risk is high, a statin is indicated. Those with borderline or intermediate risk may benefit from a statin, depending on other factors.

What Are Statins?

Statins are drugs that improve cholesterol and have anti-inflammatory effects. Many studies have proven the profound benefit of statins for preventing heart attacks, strokes, and death from CVD.³⁷

The following are steps that individuals can consider taking in order to play an active role in prevention of heart disease and stroke:

• Ensure you have had appropriate screening tests, like a cholesterol panel and hemoglobin A1c to check for diabetes.

• Confirm whether or not you should be on a statin and whether your cholesterol is where it should be.

• Know your ASCVD risk and what it means for you. ASCVD may under or overestimate risk in certain ethnicities. Ask a healthcare provider if your risk is accurately reflected.

• If your ASCVD risk indicates that you have intermediate risk and you are not on a statin, discuss this with a healthcare provider. Tests like coronary artery calcium score can sometimes help with the decision to start statins.

• If you are not tolerating any of your prescribed medications, speak with a healthcare provider about alternative medications or dosing strategies. For example, some people who experience side effects on one statin will tolerate another statin. Others have success with a lower dose or taking it every other day.

• Let a healthcare provider know if you are having difficulty affording medications. Oftentimes more affordable alternatives exist. If you have insurance, sometimes one medication will be covered when a similar medication is not.

• Other medications that have a role in CVD prevention are high blood pressure and diabetes medications. If you have either of these conditions, ask your healthcare provider if your numbers are where they should be.

• If you think you could benefit from seeing a nutritionist, weight management specialist, or diabetes specialist, ask a provider for a referral. Of course, not everyone has access to these services, but for those who do, they can be extremely valuable.

Summary

While cardiovascular disease can affect anyone, health disparities contribute to higher incidence and worse outcomes for certain groups. This is in part due to differences in CVD risk factors and prevention.

Social determinants of health are responsible for many of these inequalities. Continued research to understand these risk factors, as well as societal and institutional commitment, are necessary to achieve health equity in CVD prevention.

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By Angela Ryan Lee, MD
Angela Ryan Lee, MD, is board-certified in cardiovascular diseases and internal medicine. She is a fellow of the American College of Cardiology and holds board certifications from the American Society of Nuclear Cardiology and the National Board of Echocardiography. She completed undergraduate studies at the University of Virginia with a B.S. in Biology, medical school at Jefferson Medical College, and internal medicine residency and cardiovascular diseases fellowship at the George Washington University Hospital. Her professional interests include preventive cardiology, medical journalism, and health policy.