Black, Hispanic Individuals Bear Pandemic’s Brunt: AHA COVID-19 CVD Registry

Most of the hospitalizations and deaths captured by the American Heart Association (AHA) in its COVID-19 CVD Registry involve Black or Hispanic people, data collected up to July 22, 2020, show.

These groups accounted for 59% of hospitalizations and 53% of deaths, far above the proportion of Black or Hispanic individuals in the general population, Fatima Rodriguez, MD (Stanford University, CA), reported during the virtual AHA 2020 Scientific Sessions.

Significant racial/ethnic disparities in terms of in-hospital death and MACE were not observed, although Asians/Pacific Islanders had the highest cardiorespiratory disease severity at presentation of any group.

“Although race and ethnicity was not independently associated with our clinical outcomes, Black and Hispanic patients bore a greater burden of morbidity and mortality due to their disproportionate representation,” Rodriguez said during her presentation. “And our work emphasizes that interventions to reduce disparities should move upstream from hospitalizations.”

At a press briefing, co-author James de Lemos, MD (University of Texas Southwestern Medical Center, Dallas), said, “Unfortunately, these are deeply-seated problems in US society. There aren’t any easy solutions. I do take some comfort in the fact that there are no obvious disparities once patients reach the hospital. I think that care looks generally similar and outcomes look similar, but we have a ton of work to do even before this pandemic is over to try to stem this tide.”

Harriette Van Spall, MD (McMaster University, Hamilton, Canada), who was not involved in the study, pointed out that equity in healthcare is not an isolated issue.

We have a ton of work to do even before this pandemic is over to try to stem this tide. James de Lemos

“It is impossible to have health equity without social equity and economic equity. Health begins in utero and there are so many determinants that impact survival before patients hit the healthcare system,” Van Spall said. For COVID-19 in particular, she continued, “how effective is mask wearing and social distancing when you are in a crowded household with multigenerational family members, [with] some . . . who have to go out to work in factories that are congested and do not have appropriate protocols in place because their workers have minimal rights? What is it like to live in a neighborhood where you do not access the same prevention strategies as you would if you live in a different postal code? I do think that society in the US has adapted to huge disparities, and some of those have to be tackled before we are able to close gaps in healthcare delivery.”

AHA COVID-19 CVD Registry

The COVID-19 pandemic “has magnified existing and pervasive racial/ethnic disparities in the US,” Rodriguez said, noting that prior research has shown that Black and Hispanic patients are more likely to develop COVID-19 and have severe outcomes. Those studies, however, have been limited in that they’ve been conducted at single centers or were ecological in design, she added.

The study presented during AHA 2020, published simultaneously online in Circulation, was based on the COVID-19 CVD Registry, set up to better understand hospital outcomes and adverse CV complications associated with the viral infection. The analysis focused on 7,868 patients who were enrolled across 88 registry sites between January 1 and July 22 and for whom race/ethnicity information was available.

Overall, 35.2% of patients were non-Hispanic white, 33.0% Hispanic, 25.5% non-Hispanic Black, and 6.3% Asian/Pacific Islander. White patients made up a lower proportion, and Black and Hispanic patients a greater proportion, compared with local census data.

On average, Black and Hispanic patients were younger than others. Hispanics had the highest rate of being uninsured or self-paying (12.8% vs 2.5-5.0% in other groups). Asian/Pacific Islander patients had the longest median time from symptom onset to hospital arrival (7 vs 5-6 days). Looking at comorbidities, Black patients had the highest rates of hypertension (69.9%), diabetes (45.2%), and obesity (49.3%). A separate registry analysis of body mass index in relation to disease severity was presented in the same late-breaking session, showing that Black Americans hospitalized for COVID-19 made up the largest proportion of patients with the most severe obesity, with Hispanic patients accounting for almost one-quarter.

In the hospital, about one-third of patients required ICU admission. Black patients were most likely to need mechanical ventilation (23.2%) and new renal replacement therapy (6.6%). The most common COVID-19 therapy used was hydroxychloroquine in roughly 40%. Remdesivir, “which probably has the best evidence base during the study period,” according to Rodriguez, was rarely used, with use lowest in Black patients (6.1% vs 8.0-9.5%).

Overall in-hospital mortality and MACE (death, MI, stroke, new-onset heart failure, or cardiogenic shock) rates were 18.4% and 21.4%, respectively. Multivariable analyses showed no significant differences across racial/ethnic groups for either outcome. A cardiorespiratory-specific COVID-19 disease-severity scale adapted from the World Health Organization’s classification indicated worse severity in Asian/Pacific Islander patients versus non-Hispanic whites (OR 1.48; 95% CI 1.16-1.90).

‘It’s Risk, Not Race’

Commenting for TCTMD, Kim Williams, MD (Rush University Medical Center, Chicago, IL), a past president of the American College of Cardiology, focused on the factors that put Black and Hispanic people in a position to be disproportionately affected by COVID-19. For one, there are the “structural racism issues that have plagued this country for centuries,” he said, pointing to disparities in the quality of education and healthcare available to these communities. The AHA highlighted these and other structural racism-related issues in an advisory released in the days leading up to its virtual meeting.

“You take that and magnify it to every aspect, not just education—although I believe that education is the most important—and you end up with people who are just trying to survive. They have to go to work in order to eat. They can’t isolate themselves in a large condo with very few people. They don’t have any of those options,” Williams said. “So the structural racism that has happened over the centuries has led to taking out the people [during the pandemic] who have the least capacity to deal with such an illness.”

Everyone should just face the fact that we need to fix the structural racism that makes people at risk for any kind of illness like this. Kim Williams

Another big issue underlying the greater impact of the pandemic on racial/ethnic minority communities is the elevated prevalence of cardiovascular risk factors among these groups, he said, adding that “any community that has a high incidence of diabetes, hypertension, obesity, and high cholesterol is going to fare worse once they have the disease.”

That underscores the importance of maintaining healthy lifestyle habits to mitigate the impact of COVID-19, Williams argued. Patients of his who eat a vegan diet and who exercise regularly, for instance, have fared better over the last several months, he said. “Lifestyle really, really matters. That’s really what this paper is saying.”

The bottom line, Williams said, is that “it’s risk, not race. Everyone should just face the fact that we need to fix the structural racism that makes people at risk for any kind of illness like this and fix the risk factors in our community. And that has to do with education, [and] it has to do with the community culture and nutrition practices. This is not the first time it’s been called out.”

It’ll take a combination of legislation, regulation, and education to tackle these issues, Williams stressed. “You put those three things together to try and get the population to have a healthier lifestyle,” he said, touting the importance of regular exercise and a healthy diet. “If you do those things, COVID will be there, but COVID isn’t going to kill people. It’s not going to overwhelm our hospitals.”