Black women receive inadequate cardiac care compared to whites despite greater risk, study finds

By Camille Mojica Rey

Researchers have had few clues as to why Black women are more likely to die from heart attacks or strokes than white women. But, now a national study led by researchers at the San Francisco VA Medical Center (SFVAMC) indicates that the difference in cardiovascular-related deaths may be attributed, in part, to the inadequate medical care Black women receive from their health care providers.

“We found that Black women had nearly twice the rate of heart attack and death due to coronary heart disease. Despite this greater risk of coronary events, Black women were less likely to have adequate blood pressure and cholesterol management and less likely to receive preventive treatment,” said Ashish K. Jha, MD, lead author on the paper. Jha was a physician in general internal medicine at the SFVAMC and a UCSF assistant professor of medicine at the time he conducted this research.

According to Jha, the study’s findings indicate that physicians need to change the way they view and treat heart disease in Black women. “One of the things that should guide cardiovascular therapy is that people at higher risk should be treated more aggressively,” said Jha, who is now a research fellow at Boston’ s Brigham and Women’s Hospital and the Harvard School of Public Health.

Because of their increased risk, Black women with heart disease should ask more questions, said senior author, Michael Shlipak, MD, MPH. These women should ask about diabetes screening, their blood pressure and cholesterol levels, and about what is being done to prevent a heart attack, said Shlipak, SFVAMC staff physician and UCSF assistant professor of medicine and epidemiology and biostatistics. “We don’t really know if the undertreatment of Black women is being driven by physicians or patients. But, the more women are empowered to participate in their cardiac care, the better off they will be,” he said.

The study, which appears in the August TK online issue of Circulation, is the first to look at quality of care, risk factor control and clinical outcomes in a large group of women over time. The researchers used data from the Heart and Estrogen/progestin Replacement Study (HERS), a large clinical trial set up to evaluate the role of hormone therapy in women with heart disease. To qualify for the HERS study, women had to have been diagnosed with coronary heart disease and many of them had already suffered heart attacks or life-threatening irregularities in their heartbeats. The HERS trial included 2,699 women under the age of 80 from 20 medical centers nationwide. Eight percent (218) of the participants were Black. The average follow-up time for these participants was 4.1 years.

The researchers found that, when they adjusted for age, Black women were over twice as likely to both experience and die from a major cardiac event when compared to white women. Black women were, however, sicker when they entered the study, Jha said. Still, when researchers controlled for age, social factors and initial health status, Black women were still 60 percent more likely than to have a heart attack or die from heart disease.

Overall, researchers observed poor control of risk factors that could lead to subsequent life-threatening cardiac events. Black women had higher rates of high blood pressure, diabetes and high cholesterol. About 56 percent of Black women had adequate blood pressure control, versus 63 percent of white women. Only 30 percent of Black women and 38 percent of whites had acceptable cholesterol levels.

Researchers also found that, despite their higher risk of heart disease, Black women were 10 percent less likely to be taking aspirin and 27 percent less likely to receive cholesterol-lowering drugs, called statins.

Jha and his colleagues argue that these differences are not likely due to the failure of Black women in this study to adhere to their doctor’s instructions. Black women in the study were as compliant as white women when it came to follow-up visits and taking study medications as white women. Researchers believe economic disparity was unlikely a factor in producing these results because Black women showed slightly greater use of expensive drugs, including ACE inhibitors and calcium channel blockers. The design of the study did not allow researchers to measure physician prescribing behavior.

Because women in clinical trials tend to be more health conscious than other women, the disparity in cardiac care of white and Black women—and the care of women in general—is likely to be worse in the general population, researchers said. “Interventions are needed to improve and equalize preventative therapy use in all racial groups,” they wrote.

Additional authors included Paul D. Varosy, MD, UCSF cardiology fellow; Alka M. Kanaya, MD, UCSF assistant professor of medicine; David D. Waters, MD, FACC, UCSF professor of cardiology and chief of cardiology at San Francisco General Hospital; Donald B. Hunninghake, MD, University of Minnesota School of Medicine, Minneapolis, Minnesota; Mark A. Hlatky, MD, Stanford University School of Medicine, Palo Alto, California; Curt D. Furberg, MD, PhD, Wake Forest School of Medicine, Winston-Salem, North Carolina.