Keith C. Ferdinand, MD: Heart Failure Disparity in the US
October 05, 2019
How disparities in cardiovascular disease and its comorbidities most commonly present, unfortunately, is in patient mortality. Black patients have been notably burdened by a greater rate of cardiovascular mortality risk for years now, and are continuously under-represented in major clinical trials.
In an interview with MD Magazine®, Keith C. Ferdinand, MD, Gerald S. Berenson Endowed Chair in Preventive Cardiology and professor of Medicine at Tulane University School of Medicine, explained the burden of race disparity in cardiovascular disease, and whether potential therapies may help reduce it.
MD Mag: What is the disparity of heart failure among patient subgroups? How can it be lessened?
Ferdinand: If you look at the rates of cardiovascular disease, it's starting to plateau. So, after it decreased for several decades, it started to plateau or slow in its decline, and that's been seen both in white and black patients in the United States.
Nevertheless, there still is a white-black death gap, whereas in the black patients you have higher degrees of cardiovascular mortality including heart attacks, heart failure, chronic kidney disease, end-stage renal disease, and stroke, compared to the white patients.
Those disparities are part of the fabric of the healthcare delivery system in the United States that must be addressed. We need to make sure that patients have good access to health care, health insurance, have an identifiable source of primary care, have appropriate referral to specialists and on a one-to-one basis, we need to address our patients to understand their disease process and why it's necessary to take medicines or have certain diagnostic tests.
When we talk to our patients, we shouldn't try to show how smart we are, using very technical language, but use literacy appropriate, culturally appropriate language, that the patient can understand his or her condition—and why it's important to change lifestyle and take medications when needed.
MD Mag: Could SGLT2 inhibitors play a role in lessening the disparity of heart failure burden among patients?
Ferdinand: When we look at cardiovascularconditions, including heart attacks,strokes, chronic kidney disease, end-stagerenal disease—they're much higher in theAfrican-American population.
Unfortunately, many of our landmarktrials have underrepresented Americanblacks, while they're disproportionatelyaffected by these conditions. There areonly about 2-3 or 4%of those large, randomized trials.
Thatbeing said, it makes sense for patientswho tend to have salt-sensitive, low renin hypertension. SGLT2 inhibitors—whichappear to increase the secretion ofexcess sodium, excess water, to make theendothelial function improve—may bebeneficial in that population.
If youlook just at the Medicare registry—andall taxpayers pay for persons who haveend-stage renal disease because Medicarewill ensure their care on dialysis at atune of anywhere from $95 to $120 thousand a year—whereas African Americansare only 12% to 13% of thepopulation, there are over 35% ofthe persons who are on dialysis.
Therefore we can save cost to thepopulation, we can save death anddisability, by treating patients moreambitiously. I think the SGLT2 inhibitors, which have been shown now to protectagainst kidney disease, heart failure, andoverall cardiovascular disease —especially because they have an abilityto excrete excess sodium and water—maybe really beneficial in theAfrican-American population.
In a studythat I did that was published incirculation this year, we showed robustlowering of blood pressure inself-identified African Americans. Perhaps in the future we can do a betterjob in cardiovascular outcomes trials tomake sure that they're reflective of aheterogeneous population that we havehere in the United States. That beingsaid, at this point, I think SGLTinhibitors as part of the cocktail oflowering cardiovascular risk, should bebeneficial for African Americans.
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