Despite Gains, Black Americans Still Face Higher CV Mortality

Black Americans have experienced a disproportionately high rate of cardiovascular mortality compared with white Americans over the past two decades despite overall improvements in care, according to new data. The disparities are present across the spectrum of heart disease, from ischemic heart disease to hypertension as well as cerebrovascular disease and heart failure.

The findings were published in the Journal of the American College of Cardiology ahead of Juneteenth, the day marking the end of slavery in the United States. As the findings make clear, striking inequities persist in the US healthcare system more than 150 years later.

“Our study reveals that Black Americans, because of their higher cardiovascular mortality rates compared with white Americans, have suffered almost 800,000 excess deaths, which translates to about 24 million additional years of life lost between 2000 and 2022,” senior author Harlan M. Krumholz, MD (Yale New Haven Hospital, CT), who also serves as the journal’s incoming editor-in-chief, said in a press release. “This staggering figure highlights the critical need for systemic changes in addressing cardiovascular inequities.”

Melvin Echols, MD (Morehouse School of Medicine, Atlanta, GA), a co-author of the paper and chief of diversity and inclusion for the American College of Cardiology, told TCTMD in an email that the study should motivate everyone involved in healthcare to assess their implicit biases and how they might be affecting their treatment decisions.

“The first step for providers and everyone with a vested interest in healthcare is to be vigilant about their decisions and aware of their automatic feelings about a patient,” he said. “Ensure that we treat our patients equitably to combat disparities and enhance their health.”

Individual actions are only part of the solution, however. Echols also called for structural changes. “The work for health equity continues, but the work alerting the public to the ongoing disparities that we continue to see also needs to progress,” he said. “This is not a ‘blame game’ of findings, although we should not fritter away accountability for our individual and collective choices. Our society needs us all to try to do better and be better as people, communities, and systems of care, but that commitment starts with you.”

Mortality Over 20 Years

For the study, Adith S. Arun, BS (Yale New Haven Hospital), Krumholz, and colleagues looked at national death certificate data from the US Centers for Disease Control and Prevention’s Wide-ranging ONline Data for Epidemiologic Research (WONDER) between 2000 and 2022. They stratified individuals according to 5-year age groups as well as by non-Hispanic Black and non-Hispanic white populations.

Total excess age-adjusted mortality rates (AAMR) for cardiovascular disease in females decreased from 164.8 per 100,000 in 2000 to 95.1 in 2012. These rates plateaued, then spiked to 113.1 in 2020 before returning to pre-pandemic levels by 2022. Similarly, for males, this measure decreased from 195 per 100,000 in 2000 to 142 until it hit a plateau in 2011, then increased to 186.7 in 2020 before returning to pre-pandemic levels by 2022.

Overall, Black women and men had an extra 362,887 and 416,500 excess deaths as well as 11.2 and 12.5 million excess years of life lost, respectively, compared with their white counterparts.

These findings were maintained when the causes of death were broken into subcategories of ischemic heart disease, hypertension, cerebrovascular disease, and heart failure.

Excess CVD in Black vs White Americans 2000-2022

“Despite the triumphant reduction in cardiovascular morbidity and mortality over the last 50 years, those declines evolved at racially disproportionate rates resulting in not just health inequities, but life inequities,” the authors write. “Moreover, the sharp increases during the pandemic indicate the specific vulnerability of this group during a public health crisis and the need to mitigate this risk in future pandemics.”

Specifically, Krumholz told TCTMD in an email, “the study’s findings put in human terms the enormity of lost years of life because of higher cardiovascular death rates in Black Americans.”

Calling the findings “tragic,” he urged the cardiovascular community to take action. “We cannot accept these disparities as inevitable and must hold ourselves accountable for addressing the forces that produce these excess years of life lost and finding a path to meaningful progress,” Krumholz said.

‘A Stark Reminder’

In an accompanying editorial, Jennifer H. Mieres, MD, Jeffrey T. Kuvin, MD, and Robert O. Roswell, MD (all Northwell Health, New Hyde Park, NY), write that the study “provides a stark reminder that despite the significant advancements in the treatment of CVD persistent disparities in care and outcomes disproportionally affect Black Americans.”

They argue that social determinants of health as well as structural racism are to blame for much of the excess cardiovascular mortality observed in Black Americans and call for a refocusing of efforts in closing that gap. “Advancing equity in CV health and healthcare is possible, actionable and should be a top priority of the entire CV community, including healthcare systems and CV teams,” Mieres and colleagues stress.

Advances in digital health, specifically artificial intelligence, should help speed along improvements in care for all, but especially for marginalized populations, they say, adding that this still must be implemented with intent.

However, rising costs “risk undermining advances in the delivery of equitable healthcare,” according to the editorialists, who add that the US Centers for Medicare & Medicare Services’ efforts to integrate health equity into payment structure are a start.

“It is imperative that the evolution of CV care is accelerated with sharp focus on equity and quality in order to benefit underserved populations,” they write. “A strategic and implementable approach that links equity of care to quality CV care delivery with the involvement of key stakeholders of health systems, communities, and the clinical team is critical to move from awareness of CV health inequities to actionable solutions to achieve equity in CVD outcomes.”