The COVID-19 pandemic did not create disparities in heart failure outcomes between White patients and patients of color, but it did bring these disparities to light. Moving forward, addressing these disparities will require a better understanding of the historical factors that contributed to them, improved data collection to inform solutions, and strong leadership. This was the message conveyed by speakers at the European Society of Cardiology’s joint session with JAMA Cardiology, held on the final day of the 2023 Congress, titled “Achieving Global Health Equity: A New Challenge in Heart Failure.”
The session, moderated by Robert Bonow, MD, MS, and Bettina Heidecker, MD, featured four speakers: Shrilla Banerjee, MD, Karen Sliwa, MD, PhD, Sadiya Khan, MD, MSc, and Clyde Yancy, MD, MSc. Banerjee began the discussion by introducing the term “BAME,” which stands for “Black and minority ethnic.” This term emerged during the pandemic to describe populations that experienced higher rates of deaths and severe disease. Banerjee explained that the term was meant to include all populations that were not White, highlighting the idea that whiteness is often viewed as being at the center of society.
She presented data from the United Kingdom, showing that BAME populations, including those of Pakistani, Indian, Black Caribbean, Black African, and Bangladeshi origin, had higher mortality rates compared to the White UK population. This disparity was not limited to patients but also seen among healthcare workers, with the first 11 healthcare workers who died from COVID-19 being non-White. Banerjee emphasized that COVID-19 did not cause these health disparities but rather revealed and amplified them.
Banerjee discussed studies that revealed differences in the management and outcomes of acute myocardial infarction (MI) between different racial groups during the pandemic. The evidence showed that the BAME population had higher admission rates for acute MI but were less likely to receive guideline-indicated care, leading to increased mortality compared to the pre-COVID-19 period. She emphasized that the increased mortality among patients of color had no genetic basis but was instead influenced by social determinants of health and physician implicit bias.
Implicit bias, Banerjee explained, comes from a person’s environment and is shaped by a lifetime of exposure to messages from friends, family, media, and culture. Structural racism, on the other hand, results from policies that disadvantage racial and ethnic minority groups in areas such as education, healthcare, employment, housing, and law enforcement. Banerjee argued that addressing racism should be treated as a public health crisis, just like other risk factors such as obesity, diabetes, and lack of physical activity.
Sliwa focused on heart failure in Africa, highlighting the lack of data on the incidence and nature of the disease on the continent. She explained that heart failure in Africa looks different from other parts of the world, with women and younger patients being more commonly affected, and mortality rates as high as 20% at 6 months. The drivers of heart failure in Africa are diverse, including factors such as streptococcus throat infections, genetic factors, rheumatic fever, and chromatic heart disease.
Limited access to healthcare and diagnostic tools like echocardiography contribute to a lack of diagnosis and poor prognosis for many African patients. Sliwa mentioned peripartum cardiomyopathy as a common condition contributing to acute heart failure in African countries, especially in Nigeria. Inadequate prenatal care and complications related to childbirth further exacerbate the situation. Sliwa highlighted the importance of guideline-directed therapy in reducing death and readmission rates for acute heart failure and emphasized the challenges in making these therapies widely available in Africa.
In conclusion, the speakers stressed the need for a comprehensive approach to addressing disparities in heart failure outcomes. This includes addressing implicit bias and structural racism in healthcare, improving data collection and representation in clinical trials, and advocating for all patients. By understanding the historical factors that created these disparities and working towards equitable solutions, progress can be made towards achieving global health equity in heart failure care.