Racial Differences in How Patients Perceive CVD Risk Should Spur Rethink in Management

NEW ORLEANS, LA—Not only do African-American patients underestimate their risk of cardiovascular disease—more so than their white counterparts—but they are also less willing to try risk-reducing medications. Those on statin therapy are also less likely to report side effects, according to US registry data.

Several studies have established care disparities between black and white patients, but few have pinpointed why they exist, study author Tracy Wang, MD, MHS, MSc (Duke Clinical Research Institute, Durham, NC), told TCTMD. While this study, presented yesterday in a poster session at the American Heart Association Scientific Sessions 2016, does not have all the answers, Wang said many of the racial differences stem from cultural perceptions and physiologic variations in side-effect manifestation.

“Between those two, it really becomes more of how you frame the conversation about risk,” she said. “Instead of trying to basically say, ‘Let's try and treat everyone with statins. Let's try to push a pill on people,’ it becomes more of a ‘Let's have a conversation about what you think your 10-year risk should be.’”

For the study, Wang and colleagues looked at data on 7,736 patients with or at high-risk for cardiovascular disease enrolled in the PALM registry in 2015, 14% of whom were African-American. After assessing their clinical risk via questions on an iPad in the clinic, the researchers found that the African-American patients had lower perceived risks of heart disease than did white patients (32.6% vs 36.7% in the next 10 years; P = 0.003). When asked to compare their risk to that of others of the same age and sex, African-Americans still perceived their risk to be lower than the personal risk perceptions of white patients (32.3% vs 29.5%; P < 0.001).

In parallel to this finding, white patients were more often treated with statins and at guideline-recommended doses compared with African-Americans.

Statin Utilization by Race

Among those currently or previously on statins, African-American patients were less likely than white patients to report statin-related side effects (6% vs 11%; P < 0.001). Also, African-Americans were less willing to try risk-reducing medications compared with white patients (27% vs 17%; P = 0.045).

Integrated Rather Than Race-Based Medicine

While Wang said she disagrees with the notion of practicing “race-based medicine,” the study should tell physicians that “we need to be sensitive to this, because there are definitely some cultural differences here that we need to fix.”

Some clinicians might balk at the thought of adding one more box to check during a 15-minute appointment, she said, but “we should start the conversation with the question of ‘What do you think your risk is?’ Because right now we're probably being a little paternalistic. . . . We need to take a step back and get that feedback. So if I tell you you're risk in the next 10 years is 7.2%, [ask] ‘What does that mean to you?’ And start that conversation from there rather than say, ‘Your risk is 7. Guidelines tell me I need to treat you with this. I'm going to prescribe this.’”

The interactions with the patient don't start and stop at the clinic door. Tracy Wang

Also, in the current era of medicine, “interactions with the patient don't start and stop at the clinic door,” Wang observed. “So a lot of this can be prepped before a visit and can be followed up with after a visit. I think that's where we have to think about this systems issue: how we deal with this from a sort of ‘reinventing care’ standard.

 “Wouldn't it be better if you came to see me but before you came, based on what I have about you in the electronic health record, I'm already able to get some thoughts going, some questions going for you?” she asked. “That's the kind of thing we're talking about where the interaction really shouldn't just be clinic in, clinic out. It should be beforehand, so that we can in fact be more effective during our 12- or 15-minute visit with the patient rather than just saying, ‘OK, I've got 10 things to talk about, let me prioritize the top three.’”