Academic medical centers may help mitigate structural racism in cardiovascular care for Black women

Investigators from the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai have found that among a cohort of women with obstructive coronary artery disease treated at academic medical centers, racial and ethnic disparities did not impact their long-term outcomes. The findings were recently published in the Canadian Journal of Cardiology.

The retrospective study was part of the Women’s Ischemia Syndrome Evaluation (WISE), a multiyear, multicenter research project sponsored by the National Heart, Lung, and Blood Institute to study detection and assessment of heart artery disorders in women.

The study’s senior and corresponding author Janet Wei, MD, assistant professor of Cardiology in the Smidt Heart Institute, said that a possible explanation for the findings is that evidence-based, guideline-directed cardiovascular care provided at academic medical centers can help ensure equal health opportunities for Black women, who are at an increased risk of dying from cardiovascular disease compared to non-Black women.

“Our findings suggest that when women with coronary artery disease are treated in an academic setting—as were the women involved in the WISE study—they may experience less racial and ethnic discrimination and receive appropriate guideline-directed therapy,” said Wei, who also is associate medical director of the Biomedical Imaging Research Institute and co-director of the Stress Echocardiography Lab in the Smidt Heart Institute.

While heart disease is the leading cause of death for women in most racial and ethnic groups in the U.S., previous studies have shown striking disparities in heart disease outcomes in Black versus non-Black women, including earlier development of cardiovascular disease and a nearly 20% higher rate of cardiovascular-related death.

But the reasons for these disparities have been unclear, leading Wei and other investigators to explore the factors associated with long-term adverse outcomes in Black women with obstructive coronary artery disease.

Using data from the WISE original cohort of 944 women, investigators studied middle-aged women who had coronary angiograms revealing obstructive coronary artery disease (one-third of the cohort). The women were followed for more than a decade to monitor for heart attack, stroke, hospitalization due to chest pain or heart failure, or any cause of death.

Compared with non-Black women in the group, Black women had higher rates of cardiovascular risk factors, such as obesity (average body mass index was 31 in Black women vs. 28 in non-Black women) and hypertension (90% vs. 64%); lower levels of education (50% vs. 19%) and income (62% of Black women earned less than $20,000 per year vs. 32% of non-Black women); and a higher proportion of public health insurance (51% vs. 39% were on Medicare and 21% vs. 6% were on other public insurance, while 23% vs. 49% had private insurance).

However, Black women had a similar or higher use of guideline-directed treatment, including cholesterol- and blood pressure-lowering medications, for coronary artery disease compared to non-Black women. And their long-term cardiovascular outcomes—including cardiovascular mortality—were similar to that of non-Black women with obstructive coronary artery disease (28% of Black women died vs. 20% in non-Black women).

Recent studies have attributed social determinants of health and structural racism to disparities in cardiovascular health. But if racial disparities in cardiovascular treatment are reduced, racial disparities in cardiovascular outcomes may be lessened or even eliminated.”

Janet Wei, MD, Assistant Professor of Cardiology, Smidt Heart Institute

In a separate, recent study, Cedars-Sinai investigators found that Black women with signs and symptoms of ischemia with no obstructive coronary artery disease (INOCA) have increased long-term risk of heart attack, stroke or death.

In addition, they reported that women with INOCA are less likely to be prescribed cardiac medications compared to women with obstructive coronary artery disease, in part because traditional cardiology training advises physicians to look for blockages in coronary arteries when diagnosing coronary artery disease, making INOCA a commonly overlooked cardiac condition.

“Increasing understanding and awareness of how cardiac conditions affect women is so important,” said C. Noel Bairey Merz, MD, principal investigator of the WISE clinical trial, director of the Barbra Streisand Women’s Heart Center, director of the Linda Joy Pollin Women’s Heart Health Program, and the Irwin and Sheila Allen Chair in Women’s Heart Research at the Smidt Heart Institute. “Also critical is the need for appropriate guideline-directed care for all women, regardless of where they go for treatment.”

Bairey Merz, Wei and other investigators in the WISE study into more equitable outcomes for Black women recommended that physician and community education campaigns aimed at evidence-based and guideline-directed care be used in community healthcare settings to help mitigate structural racism.