Cardiovascular Health in African Americans: AHA Statement

Carnethon MR, Howard G, Pu J, et al., on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; and Stroke Council.
Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation 2017;Oct 23:[Epub ahead of print].

The following are key points to remember about this American Heart Association Scientific Statement on cardiovascular (CV) health in African Americans:

  1. The present statement on cardiovascular health in African Americans follows statements published on Asian Americans and US Hispanic/Latinos and is intended to educate physicians and other providers on the approach to CV disease (CVD) prevention in African Americans, who have poorer overall CV health than non-Hispanic whites and CVD mortality than in whites.
  2. In 2012, the life expectancy of African Americans was 3.4 years shorter than that of whites (75.5 vs. 78.9 years, respectively). CVD is estimated to explain over 30% of their excess mortality. There is no difference in incident coronary heart disease (CHD) between African Americans whites. However, African American men and women have substantially higher rates of fatal CHD than whites (men: hazard ratio [HR] = 2.18; women: HR = 1.63).
  3. Both sudden cardiac arrest and sudden cardiac death are higher in African Americans as compared with whites, due primarily to a higher burden of traditional and nontraditional (e.g., sickle cell trait) CVD risk factors. On average, they are >6 years younger than white counterparts and less likely to survive to discharge (25.2% vs. 37.4%). In contrast, while African Americans have more risk factors for the development of atrial fibrillation, there is a lower incidence, described as the “atrial fibrillation paradox.” Incident atrial fibrillation is approximately 0.20-0.50 times lower in African Americans than their white counterparts across the adult age spectrum.
  4. An analysis of trends indicates that rates of hypertension among African Americans remain approximately 10-12% higher than rates among non-Hispanic whites and Mexican Americans. The origins of adult differences in hypertension begin in youth. African American boys and girls have higher blood pressure levels and a higher prevalence of hypertension. African Americans, however, are more likely than whites or Hispanics to be aware of their hypertension and have it treated. The magnitude of the association between systolic blood pressure (SBP) levels and stroke risk is 3 times greater in African Americans than in whites (10 mm Hg difference in SBP in whites is associated with an 8% increase in the stroke risk, but a 24% increase in African Americans).
  5. Diabetes is considerably more common in young African Americans through all ages. Similarly, obesity rates are higher among African Americans. Among the reasons for increased obesity include the cultural attitudes of favor for a larger body size, particularly for women, and diet of high-fat meats and deep-frying cooking with excess calories and salt, and decrease in leisure time physical activity. African Americans have an excess burden of chronic kidney disease, owning in part to the high prevalence of hypertension and diabetes, but that may also be the result of the percent of African admixture and other genetic factors including sickle cell trait.
  6. Lipids per se underestimate CVD risk in African Americans in younger cohorts. However, the relative risk of dyslipidemia in African Americans compared to whites increases with age. Undertreatment with statins in African Americans requires specific attention by providers and increased adherence by patients. Mortality from all CVD is significantly higher in African Americans as compared with whites, which suggests a role for healthcare to mitigate disparities with comprehensive screening, an enhanced specificity of diagnoses, and tailored disease management. The prominence of disparities in the onset of CVD at younger ages highlights the contribution of CV risk factors and adverse health behaviors among African Americans.
  7. Guidelines for pharmacologic management of CVD in African Americans do not differ from management in other race/ethnic groups. However, there are two notable exceptions, heart failure with left ventricular (LV) systolic dysfunction and hypertension, where African American patients may benefit from tailored treatment approaches. This conclusion is based on lack of benefit from angiotensin-converting enzyme (ACE) inhibitors in early trials, which were inadequately powered to draw conclusions. Presently, African Americans with New York Heart Association class III or IV heart failure and reduced LV ejection fraction should be treated with a beta-blocker and aldosterone antagonist in combination with hydralazine and isosorbide dinitrates with consideration for ACE inhibitors, particularly if there is renal disease. Hypertensive African Americans appear to respond better to diuretics (chlorthalidone) and calcium channel blockers than ACE inhibitors. However, the latter were shown to be better able to slow the progression of renal disease and proteinuria as well as combined endpoints of end-stage renal disease and death in patients with hypertensive renal disease.
  8. There are many barriers that need to be overcome before we will see a reduction in the CV risk factors in African Americans. Among them include education regarding nutrition and disease prevention in the young, and early detection and intervention by health care professionals. Whether combining genomic with phenotypic information will help in characterizing individual risks and treatment for CVD in African Americans will require much larger studies than are presently available.

Editor's note: The American College of Cardiology has endorsed this document.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Diet, Exercise, Hypertension

Keywords: African Americans, Angiotensin-Converting Enzyme Inhibitors, Atrial Fibrillation, Blood Pressure, Calcium Channel Blockers, Cardiovascular Diseases, Death, Sudden, Cardiac, Disease Management, Diabetes Mellitus, Diet, Diuretics, Dyslipidemias, Exercise, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Kidney Failure, Chronic, Leisure Activities, Life Expectancy, Lipids, Metabolic Syndrome X, Mineralocorticoid Receptor Antagonists, Obesity, Primary Prevention, Renal Insufficiency, Chronic, Risk Factors, Sickle Cell Trait, Stroke

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