Black women receive less care for coronary heart disease than whites, despite greater risk

American Heart Association
Tuesday, 26 August 2003

Black women are twice as likely as white women to have or die from coronary heart disease, but are less likely to receive adequate treatment, according a report in today's rapid access issue of Circulation: Journal of the American Heart Association.

The study is the first to simultaneously evaluate medical treatment, risk factor control and clinical outcomes in a large group of women with heart disease followed over time.

"Heart disease is the biggest cause of death for women in this country and there are large gaps in outcomes between black and white women," says lead author Ashish K. Jha, M.D., a general medicine fellow at Brigham and Women's Hospital and the Harvard School of Health in Boston. "We did the study to better understand the differences in quality of care in the two groups."

Jha was an assistant professor of medicine at the University of California San Francisco and a general internal medicine physician at the San Francisco VA Medical Center at the time of the study. Researchers used data from the Heart and Estrogen/progestin Replacement Study (HERS), a large clinical trial that initially evaluated the role of hormone therapy in women with heart disease. HERS enrolled 2,699 women under age 80 from 20 medical centers nationwide. Eight percent of the women (218) were black.

During the average 4.1 years of follow-up, cardiovascular events were twice as common in black women as in white women (6.4 vs. 3.1 per 100 person-years). Black women also had a two-fold greater risk of cardiac death (16 percent vs. 8 percent) than white women.

Poorer control of cardiovascular risk factors may account for part of the difference. Black women had higher rates of high blood pressure, diabetes and high cholesterol. About 56 percent of the black women in the study had adequate blood pressure control, versus 63 percent of the white women. Black women had acceptable cholesterol levels 30 percent of the time versus 38 percent of the time for white women.

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

Researchers ruled out economic reasons because black women used more expensive drugs including ACE inhibitors and calcium channel blockers than white women. They also note that black women and white women in this study were equal in adherence to clinical follow-up and study medications. Researchers were unable to measure physician bias in prescribing practices.

Women who enroll in clinical trials may be more health conscious than other women, so disparities in this group may mean larger differences in the general population.

Jha says the results are troubling.

"High-risk patients should be treated aggressively," he says. "Yet, in this study, we found that women who are at higher risk were actually being undertreated. I think it suggests that clinicians should be more aware of cardiovascular risk issues in all women, but black women in particular, and be more aggressive with treatment and management of this higher-risk group."

Women are known to underestimate their risk of heart disease. These results should drive home the fact that they need to be more aware of heart disease risk factors and how to control them, he says.

"We need interventions that improve appropriate therapy and risk factor management for all women, but especially for this higher-risk group," Jha says.

The next step in research is to see what works, Jha says. "We need to design interventions that improve therapy and management for women with heart disease. The next set of studies really needs to focus on evaluating interventions that work at narrowing gaps between black and white women."

In an accompanying editorial, William S. Weintraub, M.D., professor of medicine, and Viola Vaccarina, M.D., Ph.D., associate professor of medicine, at Emory University, Atlanta, say that Jha and colleagues raise more questions than they answer. "Clearly these black women are at great risk. Coexisting disease and risk factors, and differences in treatment explain some but not all of the outcome differences between black and white women," they write. "These are critical issues, because until disparities are well understood, it is difficult to design optimal programs to overcome disparities and give all people, no matter what their color, the best chance at the best outcome as efficiently as we can."

Co-authors are: Paul D. Varosy, M.D.; Alka M. Kanaya, M.D.; Donald B. Hunninghake, M.D.; Mark A. Hlatky, M.D.; David D. Waters, M.D.; Curt D. Furberg, M.D., Ph.D.; and Michael G. Shlipak, M.D., M.P.H.

Editor's note: To help women reduce their risk for cardiovascular disease – the No. 1 cause of death for American women – the American Heart Association offers Simple Solutions. This free education program helps women incorporate simple healthy changes into their lives to improve their heart health. Join Simple Solutions by logging on to americanheart.org/simplesolutions.

For more information, or to contact American Heart Association, see their website at: www.americanheart.org