Feb. 22, 2023 – It was week 17 of what should have been a typical Monday Night Football showdown featuring the Buffalo Bills and the Cincinnati Bengals. But Bills safety Damar Hamlin’s tackle of Bengals receiver Tee Higgins may ultimately have been a game changer – not only for football, but for heart disease disparities in the U.S. as well.
Hamlin, 24, who had sudden cardiac arrest after getting hit in the chest by Higgins’s right shoulder during the first quarter of the Jan. 2 matchup, was down for roughly 19 minutes while first responders did cardiopulmonary resuscitation (CPR) and used an automated external defibrillator (AED) to restart his heart. The incident – which has focused attention on a rare condition (commotio cordis) and the importance of public action – may also be a turning point for a community that has long been in the spotlight for having poor heart health: Black Americans.
“Even though we’ve made tremendous progress in reducing the burden of heart attack and stroke, we need a different approach to get everyone’s attention,” says Clyde Yancy, MD, chief of cardiology and vice dean for diversity and inclusion at Northwestern Medicine in Chicago, and past president of the American Heart Association.
“Case in point is the episode with Damar Hamlin; everybody in the country is now aware of the benefit of CPR,” he says. “We haven’t always been able to leverage a moment that gets the attention of the community in such a rapid and robust way.”
This especially true of many Black Americans, for whom community support for health and wellbeing is common.
“That’s the beginning of change that can happen across the board,” Yancy says.
Persisting Disparities, Social Ties
Increased rates of heart failure, stroke, and narrowed blood vessels that reduce blood flow to the limbs (peripheral artery disease) also disproportionately affect Black Americans, even though overall rates of coronary heart disease are not significantly different than those found in white peers.
Moreover, recent findings from the ongoing Multi-Ethnic Study of Atherosclerosis (hardening of the arteries) show that compared with white, Chinese, and Hispanic people, Black people had the highest rates of dying from all causes, and after adjusting for age and sex, a 72% higher risk of dying from heart disease vs. white peers.
“Once we adjusted for social determinants of health, the differences between Blacks and whites for the likelihood to die nearly went away,” explains Wendy Post, , MD, a professor of cardiology at Johns Hopkins Medicine in Baltimore and lead author of the study. “Meaning that if we had the same environment, we probably would have similar mortality rates.”
With regard to “environment,” Post is referring to the impact of non-medical factors on health outcomes, better known as social determinants of health. More and more, research is focusing on how these factors tend to sustain health inequities and worse cardiovascular outcomes in Black Americans.
“We’re beginning to understand that this significant increase in cardiovascular disease is due to significant differences in social determinants of health. This can include everything from access to routine health care, insurance coverage, medications and, also, food supply and access to healthy food,” says Roquell Wyche, MD, a Washington, DC-based cardiologist.
Wyche explains that social determinants of health can also “include housing, access to a healthy environment that facilitates exercise, where a person can feel safe in their environment, socioeconomic status, work and job security, and transportation. All of these have significant impacts on cardiovascular health, and African-Americans experience greater social disadvantages across all of these determinants.”
Currently, the World Health Organization estimates that social determinants of health are responsible for as much as 55% of health outcomes overall.
Quentin Youmans, MD, a cardiology fellow at Northwestern Medicine Bluhm Cardiovascular Institute in Chicago, echoes Wyche, pointing to rates of high blood pressure in the Black community as an example.
“When we think about the main primary contributor for poor health and cardiovascular health, we think about hypertension as being one of the primary causes in Black Americans. And it’s not just the prevalence of hypertension; we know that Black patients, even if they have a diagnosis, are less likely to have their blood pressures controlled,” he says.
“This [hypertension] is a very insidious disease” that can be undiagnosed and may not cause symptoms until a patient goes to the doctor with either cardiovascular disease or a stroke. “And, so, because of these factors that contribute to not having access to care, patients may have hypertension for longer.”
Importantly, access to care includes access to proven treatments. A National Institutes of Health-supported study published last month in Circulation: Heart Failure showed that Black patients treated at heart failure specialty centers were roughly half as likely to receive evidence-based, life-changing therapies (such as transplants or mechanical blood pumps known as ventricular assist devices, or VADs) as white adults.
But when the researchers accounted for things that affect health outcomes, including disease severity and social determinants of health such as education, income, and insurance, disparities remained, even when patients expressed the same preference for lifesaving treatments. In their discussion, the study authors also suggested that unconscious bias and structural racism also contribute to how these health determinants play out across many conditions.
“We need to look at and see how structural racism is really affecting African Americans, particularly in social determinants of health,” notes Wyche, who’s also leadership development chair for the American Heart Association’s Greater Washington Region Board of Directors.
Still, this is not to say that genetics are not important, but even a family tendency to have conditions linked to heart disease – such as type 2 diabetes – have direct ties to determinants of health. For example, poor access to healthy food or the ability to afford medicine can worsen diabetes or, more importantly, the ability to reverse prediabetes (the stage before diabetes) with lifestyle changes. Currently, the American Heart Association estimates that Black American men get diabetes 1.5 times more often than white men, and Black women 2.4 times more often than white women.
A Path Forward
Structural racism and even unconscious bias play key roles in keeping up poor heart health outcomes in African Americans. Yancy emphasizes how the preponderance of heart disease is both a risk and an opportunity.
“We know strategies that work; we have evidence that demonstrates that we can change the arc of this disease burden, and we can improve outcomes,” he says. “So, the greatest risk, the greatest need truly is in those who are self-described as African American or Black. But the greatest opportunity exists there as well if we deploy those things that we know to be true based on sound evidence.”
Yancy explains that in 2010, he helped lead American Heart Association efforts to drive change through the creation of “Life’s Simple 7” (updated in 2022 to Life’s Essential 8), which is a guidepost for achieving better heart health outcomes by changing certain behaviors and key measures of cardiovascular disease: diet, sleep, physical activity, smoking cessation, weight management, cholesterol, blood sugar, and blood pressure.
“Primordial prevention, which is prevention of risk itself, is a key consideration,” he says. “This really gets to the root cause of why we see hypertension and diabetes – so much of this is related to early childhood dietary decisions and physical activity.”
Now, he says, “we just have to adopt the will to make changes at the community level.”
One strategy, Wyche says, is to seek medical care in early adulthood, both to establish some sort of prevention strategy before disease develops, and to learn if risk factors such as high blood pressure or high cholesterol are already starting to drive full-blown conditions.
“Just as annual routine medical care is key, we are noticing that particularly in African American women as early as their 20s, that they’re showing evidence of cardiovascular disease.”
Another strategy is to recognize that social determinants of health and related health outcomes are commonly found across generations and families, and to see it as an opportunity.
“The main thing that comes to mind is engaging not just the patient, but recognizing that risk can sometimes be generational,” says Youmans. “If we can shift our focus [from] the individual patient and think about generations and entire families, then we might be able to encourage more people to follow the recommendations needed to achieve ideal or optimal health.”
Yancy, Youmans, Post, and Wyche remain optimistic, even amid the disparities in health care access and outcomes – and increased public attention their link to oppressive structures and policies – that both COVID-related disruptions and Black Lives Matter, respectively, have brought to the fore.
“I believe that we’ve gone through a generational movement,” says Yancy. “I think that in 10 years, we’ll see the positive yield of transformational experiences in the last 3 years with a more diversified workforce, a workforce that is more aware of the disease burden in the community members, community members that recognize the maladies of their own social environment, and leaders seeking change vis-a-vis public policy for change.”