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The Influence of Race on Heart Failure in African-American Women

Posted on: Thursday, 24 February 2005, 03:00 CST

Numerous factors contribute to the rate of heart failure in African-American women. More research is needed to elucidate and address heart failure in this population.

Heart failure (HF) is a chronic, complex, progressive disorder that has increased in prevalence to epidemic proportions in the United States over the last decade (McCullough et al., 2002). The prognosis for patients with HF is often characterized by a downward trajectory and death within 5 years of diagnosis (Masoudi, Havranek, & Krumholz, 2002).

HF is most often the sequela of coronary heart disease (CHD). Rheumatic or congenital defects, valvular disorders, and chronic obstructive lung disease also can be causative (American Heart Association [AHA], 2004). The development and progression of HF are attributed to the sustained sympathetic drive stimulated by the body's efforts to maintain sufficient cardiac output (Zevitz, 2004). Over time, the heart enlarges, weakens, and eventually loses the ability to provide adequate oxygenation to the tissues (Zevitz, 2004).

CHD is the leading cause of death in both men and women in the United States; statistics from the year 2001 placed the mortality rate at 703,455 (National Heart, Lung, and Blood Institute [NHLBI], 2004). Though still high, these figures have decreased steadily since 1980. Paradoxically, over the same period, the incidence of HF has escalated, with a three-fold rise in the rate of hospitalization for HF from 1971 to 2002 (NHLBI, 2004). The incidence of HF is projected to rise even further as medical advances expand longevity and promote the growth of the older adult population (Masoudi et al., 2002).

The most recent guidelines for evaluating and managing HF expanded on the New York Heart Association Functional Classification (NYHA-FC) system (American College of Cardiology/American Heart Association, 2001). The new guidelines consist of four stages (A - D). Stages B - D correspond to the NYHA-FC Classes 1 - 4 that group patients based on symptom severity and clinical presentation (see Table 1). The most notable addition to the guidelines is stage A. This stage recognizes the evolution of HF by inclusion of people who are considered at high risk for developing HF but have no symptoms or structural heart disease. Hypertension, hyperlipidemia, diabetes, smoking, sedentary lifestyle, obesity, alcohol abuse, and cardiotoxic drug use were identified as HF risk factors (Wilhelmsen, Rosengren, Eriksson, & Lappas, 2001).

Table 1.

Guidelines for Evaluating and Managing Heart Failure

The trend in the incidence of CHD in African Americans and Caucasians has shifted significantly over the last 30 years. In the 1960s, the mortality from CHD in African-American men was 25% lower than in Caucasian men (NHLBI, 1994), while Caucasian and African- American women had comparable mortality rates. Appreciable differences were documented in 1991 (NHLBI, 1994), when a 28% increase in mortality for African-American men placed them at 3% greater risk than Caucasian men. African-American women fared even worse, with a 33% increase in mortality from CHD as compared to Caucasian women (NHLBI, 1994). The 1999 Resource Utilization Among Congestive Heart Failure (REACH) Study (McCullough et al., 2002) revealed incidence rates for new onset HF to be 50% to 75% greater in African Americans than other racial/ethnic groups. Although research is by no means conclusive, the greater preponderance of risk factors, such as diabetes and hypertension in African Americans, is suspected to explain this disparity (NHLBI, 1994).

Alexander, Grumbach, Selby, Brown, and Washington (2002) conducted a retrospective cohort study with 64,877 enrollees to determine if the racial differences in hospital admission for HF could be attributed primarily to cardiac risk factors in AfricanAmerican patients enrolled in a large health maintenance organization. When statistical adjustments were made, race was not a significant predictor of HF, while smoking, hypertension, and other CHD risk factors revealed a strong association. One prominent exception was the subpopulation of African-American women ages 40 to 60. An increased incidence of HF admissions was seen in this group even after adjustments for other risk factors. These results suggest that race or racially associated factors may play some role in the development of CHD and HF in this group.

A review of the current literature reveals few other research attempts to provide a comprehensive analysis of the influence of race on HF evolution, treatment, and outcomes in African-American women. This may be in part because of the lack of consensus on the conceptualization of race among public health, psychosocial, and biological scientists, along with conflicting opinions about what role if any race should play in biomedical research and clinical medical practice (Williams, 1997).

The Concept of Race

In the United States, the Office of Management and Budget (OMB) recognizes five racial groups: Caucasian, African American, Asian, Native Hawaiian or Pacific Islander, and American Indian or Alaskan native. Hispanics are often considered a sixth racial group for purposes of health studies (OMB, 1997). The American Public Health Association (2003) advocates racial classification as a valid tool to measure correlations in diseases within groups. The NHLBI (1994) working group report on CHD research in African Americans also assigns merit to some method of categorization by race in biomedical research but cautions against the over-emphasis of solely genetic factors. They recommend formulating standardized definitions of race that incorporate other components, such as socioeconomic and environmental factors.

Reflective of the emergence of race as more of a social than a genetic concept, the 1996 update of the American Association of Physical Anthropology (AAPA) 1964 statement on race states, "Pure races in the sense of genetically homogeneous populations do not exist in the human species today, nor is there any evidence that they have ever existed in the past" (AAPA, 1996, p. 569). Williams (1997) suggests a useful working definition of race as "...a complex multidimensional construct reflecting the confluence of biological factors and geographical origins, culture, economic, political and legal factors, as well as racism" (p. 326).

Genetics

Controversy persists on the value of genetic research and the utility of application to clinical treatment of patients with HF. Some researchers deem it highly improbable that disparities between African Americans and Caucasians in HF morbidity and mortality can be attributed to genetic make up (Ferdinand, Serrano, & Ferdinand, 2002). Others see great promise in identifying gene variants that may play a part in the evolution and progression of HF (Small, Wagoner, Levin, Kardia, & Liggett, 2002). Because HF is thought to have a multifactorial genetic base influenced by a myriad of environmental triggers, some researchers view more extensive study of the impact of risk factors and co-morbid conditions in African Americans as a more appropriate focus, rather than an exploration of the influence of genetics on disease development and progression (Ferdinand et al., 2002).

Although more questions than answers remain, findings lend support to the value of genetic research. For example, a 1999 study was conducted with the Cincinnati Heart Failure Program (Small et al., 2002) to determine if the presence of genetic variants of α^sub 2C^- and β^sub 1^-adrenergic receptors increased the risk of HF. A significant percentage of African-American patients were homozygous for both the α^sub 2C^- and β^sub 1^- adrenergic variants, while few Caucasians were found with this genetic variation. The study concluded that these two variants act synergistically to increase the risk of HF in African Americans.

Clinical researchers have observed consistent differences between African Americans and Caucasians in the evolution of hypertension, a major contributing factor in HF. Hypertension presents at an earlier age in African Americans and responds differently to pharmacologic treatment (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2003). African Americans are more salt-sensitive, are more prone to low-renin hypertension, and have a much greater incidence of left ventricular hypertrophy (Svetkey, McKeown, & Wilson, 1996). Response to monotherapy treatment with angiotensin-converting enzyme (ACE) inhibitors and beta blockers has been less effective in African Americans. Additionally, they have a 4 to 5 times greater incidence of angioedema while on ACE inhibitors than Caucasians (Brown, Ray, Snowden, & Griffin, 1996). These clinical observations have fueled speculation that genetic variations may account for these differences.

Heart Failure Risk Factors

As previously noted, the new ACC/AHA guidelines (2001) have categorized people with known cardiac risk factors, but without structural heart disease or clinical symptoms, as the first stage of HF (Stage A). The addition of Stage A in the guidelines is designed to encourage clinicians to step up efforts to identify and initiate treatment based on risk factors. These risk factors also play a strong role in the development of hypertension and type 2 diabetes mellitus, which can increase HF risk (Caboral & Mitchell, 2003). W\hile the risk factors for CHD are the same for African Americans as for Caucasians, there are marked differences in the age of onset, prevalence, and severity of these risk factors.

Behera, Winkleby, and Collins (2000) conducted a qualitative study which used focus groups from six different community settings in Northern California to determine the knowledge and perception of CHD risk among African-American women. The participants identified high stress levels, cultural influences, financial strain, and lack of education as the reasons for the high prevalence of risk factors among their group. The cited barriers to risk factor reduction were the time constraints placed on them by work and family, unsafe neighborhoods, lack of support from private physicians, and poor access to costly health clubs. They identified television as their main source of health information, and they did not believe that the media placed the same emphasis on CHD as other health threats (for example, breast cancer). They also saw the abundance of neighborhood advertisements for alcohol and cigarettes as contributory to CHD development.

Hypertension. Uncontrolled hypertension is the predominant etiology of HF in African Americans (Wilhelmsen et al., 2001). Hypertension is exacerbated by obesity, smoking, and hypercholesterolemia - conditions that are often seen together (Ferdinand et al., 2002). Longstanding hypertension increases the risk of end-stage renal disease, stroke, coronary artery disease, and HF. The onset of hypertension is known to occur earlier in African-American males as compared to Caucasians (Wilhelmsen et al., 2001), but few studies have examined the time of onset of hypertension in African-American women. One study used data from 2,700 Caucasian and 422 African-American participants in the National Health and Nutrition Examination Survey (Geronimus, Anderson, & Bound, 1991) to evaluate the rates of hypertension in women of childbearing age. Findings revealed no difference in hypertension incidence between races in women 15 to 19 years of age. However, the gap began to widen by age 25, and African-American women were twice as likely to develop hypertension by the mid- childbearing years compared to Caucasian women. These findings suggested that hypertension may have an early onset in African- American women. Moreover, the National Center for Health Statistics (1997) reported twice the rate of heart disease mortality in African- American women ages 45 to 64 compared to Caucasian women of the same age.

Diabetes. The high prevalence of type 2 diabetes mellitus exaggerates the risk for developing CHD and HF in African-American women. A chronic, often debilitating disease, type 2 diabetes is the fourth leading cause of death among African-American women (NHLBI, 2004). The onset of the disease is insidious; many women have insulin resistance and high blood glucose levels for up to 10 years before diagnosis (Rao, 2001). By the time the symptoms of the disease become overt, long-term and often-undetected hyperglycemia may have already taken a toll on multiple organ systems. African- American women have a much higher risk of diabetic retinopathy, end- stage renal disease, and amputation than Caucasian women (American Diabetes Association [ADA], 2004). African American race is considered an independent risk factor for type 2 diabetes, along with obesity, sedentary lifestyle, hypertension, and hyperlipidemia (ADA, 2004).

Obesity and hyperlipidemia. Cultural differences in dietary practices and perception of body image may contribute to the high rate of obesity in African Americans. Unlike Caucasian women, African-American women do not associate obesity with a negative body image. African-American men are reported to consider overweight women more sexy and attractive than women who are thin-to-normal body weight (Melnyk & Weinstein, 1994). Approximately 48% of African American girls are obese as they approach adolescence, and they are more likely to have an "apple-shaped" fat distribution, a body type associated with CHD (Dekkers et al., 2004).

More African Americans have diets higher in saturated fat and calories than their Caucasian counterparts (Ferdinand et al., 2002). Some evidence suggests that cultural differences alone do not account fully for the high percentage of obesity in African- American women. For instance, African-American women reportedly spend less time engaged in regular exercise during their leisure time than Caucasian women; however, research in low-income African- American women has shown that motivation to exercise increased greatly when the women were provided with a safe environment, assistance with childcare, and programs based on activities that parallel cultural attitudes (Ferdinand et al., 2002).

Smoking, alcohol, and drugs. Smoking is the single-most preventable cause of CHD in women of all races (National Center for Chronic Disease Prevention and Health Promotion, 2001). Currently, 50% of myocardial infarctions (MI) in middle-aged women are attributed directly to cigarette smoking (Office of Women's Health [OWH], 2000). Only 9% of African-American adolescents begin to smoke before high school graduation, in contrast to 33% of Caucasian adolescents. It is not clear at what point these figures converge, but by adulthood, African-American and Caucasian women smoke cigarettes at comparable rates (NHLBI, 2004). A great deal of the research on the role of cigarette smoking in the etiology of CHD has been done primarily on Caucasian men, leaving a significant gap in knowledge about the health consequences of smoking for men and women, and African Americans and Caucasians.

The final risk factors for HF listed in Stage A of the updated ACC/AHA guidelines (2001) are alcohol abuse and use of cardiotoxic drugs. Alcohol in moderation has some positive affects attributable to arterial vasodilation. On the other hand, alcohol in large quantities causes vasoconstriction, and long-term alcohol abuse is known to accelerate atherogenesis (Mukamal et al., 2003). Illicit drug use often involves substances that are potentially cardiotoxic, such as amphetamines, inhalants, and cocaine. People with drug and/ or alcohol-induced cardiomyopathy are at high risk for developing HF (OWH, 2000).

Racism

The effect of racism on the health status of African Americans has begun to appear only recently in the medical and psychosocial literature. The terms racism and racial discrimination frequently are used synonymously. To explore the relationship between health status and racism/discrimination, the terms will be codefined as "...the beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation" (Clark, Anderson, Clark, & Williams, 1999, p. 805).

Economic and social marginalization. The most overt display of racism in the United States is residential segregation. Confinement of African Americans to high-poverty urban areas has created economic isolation. Crowded, substandard housing, inadequate school systems, poor access to health care, few job opportunities, and lack of political power to affect change have had a long-term negative impact on the health of African-American communities (Ewart & Suchday, 2002). Several researchers have hypothesized that the characteristics of these neighborhoods exert the greatest negative effect on African-American women (Geronimus, 2001; Leclere, Rogers, & Peters, 1998; Troxel, Matthews, Bromberger, & Sutton-Tyrrell, 2003; Williams, 1997). Many of the households in poor African- American neighborhoods are female-headed and include intergenerational living arrangements, circumstances that are found 40% less often in equal income Caucasian households (Ewart & Suchday, 2002).

Racism-induced stress. Both inter-group and intra-group racism are cited as potential stressors. Discrimination in hiring practices, higher education, and access to quality health care are examples of inter-group racism. Intra-group racism refers to segregation in the African-American community, creating subpopulations based on variations of skin tones. Evidence exists to indicate that exaggerated psychological and physiological stress responses to objective or subjective racism contribute to negative health outcomes in African Americans (Clark et al., 1999).

Several researchers have proposed that the direct threat to health lies not in the exposure to racism, per se, but rather in differences in racism-specific coping responses (Clark et al, 1999; Guyll, Matthews, & Bromberger, 2001). One ongoing longitudinal study of 363 women, of which 101 were African American and 262 Caucasian, found that subtle mistreatment caused an increase in diastolic blood pressure (DBP) in African-American women, but not in Caucasian women (Guyll et al., 2001). Exposure to blatant mistreatment did not cause any rise in DBP, suggesting that chronic minor stress may have a more destructive effect than occasional exposure to acute stress.

Racism in health care. The literature contains reports of several disturbing trends about disparities in medical treatment. Both African-American men and women have greater delays than Caucasians in emergency room evaluation for chest pain, and are less likely to be offered thrombolytic therapy after MI (Manhapra et al., 2001). African-American patients with MI are misdiagnosed and discharged from the emergency room without hospitalization four times more often than Caucasians (Manhapra et al., 2001). Cardiac catheterization and subsequent revascularization procedures are done significantly less often in African Americans than in Caucasians (Schneider et al., 2001). Diagnostic decisions may be influenced by health care provider bias, by deficiencies in knowledge about the atypical presentation of the African American experiencing an MI, or any number of other factors. No research cou\ld be found in the literature to attempt to explain these phenomena.

Even with quality hospital care, African Americans are much more likely to be discharged from the hospital without treatment of co- morbid conditions, and rehospitalization rates are high in this group (Alexander et al., 2002). Moreover, health care workers often fail to anticipate barriers that may contribute to treatment noncompliance and rehospitalization in African-American patients. In a comprehensive literature review of compliance issues in patients with HF over the previous decade (Evangelista & Dracup, 2000), the primary reason reported for rehospitalization of the patient with HF was the lack of adherence to expensive medication and dietary regimens after hospital discharge.

Figure 1.

A Framework for the Study of the Role of Race in Health

Finally, the effect of racism is clearly evident in clinical medical research. African-American women bear the dual burden of minority status and female gender (Troxel et al., 2003). Although the incidence of HF is escalating in African-American women, little attempt has been made to make them subjects of research. The subjects in randomized controlled studies, even those conducted with government funds, historically have consisted of cohorts of young Caucasian males. This makes any generalization of study results to African- American women questionable at best (Heiat, Gross, & Krumholz, 2002).

Frameworks and Interventions

Nursing research on the health status of African-American women must be guided by appropriate frameworks. Two frameworks that appear to have some support in the literature follow. Geronimus (1992, p. 397) describes weathering as a theorized acceleration in the aging process of African-American women. She proposes that the health disparities in these women are largely the result of long-term economic and social disadvantage. This framework was developed to study the health of African-American women and infants. The model is viewed by Geronimus (1992) as an "analytic framework to generate testable hypotheses" (p. 216). Although she has not developed a schematic for the model, it has been refined and expanded (Geronimus, 2001), and is now considered to have universal application in the study of the health inequalities of African- American women.

A Framework for the Study of the Role of Race in Health (see Figure 1) was developed by Williams (1997). This is a broad framework with racism as an explicit and central construct. The basic premise of the model is that variations in the health status of African Americans are the result of the biological responses to societal forces. Williams proposed that surface causes, which in effect are health risk factors, have been shaped by basic causes and social status. For example, racism (basic cause) and low socioeconomic status (social status) cause stress (surface cause), which in turn increases cardiovascular reactivity (biological response) and contributes to heart disease (health status). He further proposed that efforts to change surface causes without addressing the underlying basic causes will not result in any long- term improvements in the health status of African Americans, because racial and socioeconomic inequalities will continue to tilt the balance toward poor health in this population.

Conclusion

The incidence of HF has risen dramatically in African-American women. The literature suggests that the overall health of African- American women is affected negatively by a complex combination of low socioeconomic status, crowded and unsanitary housing, exposure to violence, a high rate of female-headed households, poor educational and work opportunities, and racism-induced stress. The high incidence of modifiable CHD risk factors in this population places a great number of African-American women in stage A of the AHA/ACC heart failure guidelines at an early age.

Significant barriers stand in the way of quality medical care for African-American women. Nurses who work in community settings must expand their traditional roles to include patient advocacy, participation in community development, environmental health risk assessment, and political involvement. Hospital-based nurses are on the frontline of patient care and must become attuned to the special needs, challenges, and problems faced by this population.

More study is needed at virtually every level, with particular emphasis on ethnographic studies, effective intervention strategies, genetic research, and randomized clinical trials. Conceptual frameworks that have been developed specifically for African Americans or have been modified to be culturally sensitive hold the most promise for guiding nursing research and successful intervention strategies. Complex problems require complex solutions, and nurses can play a pivotal role in improving the health status of this under-represented and under-served population.

Hypertension presents at an earlier age in African Americans and responds differently to pharmacologic treatment.

More African Americans have diets higher in saturated fat and calories than their Caucasian counterparts.

African-American women bear the dual burden of minority status and female gender.

The incidence of HF has risen dramatically in African-American women.

References

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Brown, N.J., Ray, W.A., Snowden, M., & Griffin, M.R. (1996). Black Americans have an increased rate of angiotensinconverting enzyme inhibitor-associated angiodema. Clinical Pharmacology and Therapeutics, 60(1), 8-13.

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Dekkers, J.C., Podolsky, R.H., Treiber, F.A., Barbeau, P., Gutin, B., & Sneider, H. (2004). Development of general and central obesity from childhood into early adulthood in African American and European American males and females with a family history of cardiovascular disease. American Journal of Critical Nutrition, 79, 661-668.

Evangelista, L.S., & Dracup, K. (2000). A closer look at compliance research in heart failure patients in the last decade. Progress in Cardiovascular Nursing 15(3), 97-103.

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Melnyk, M.G., & Weinstein, E. (1994). Preventing obesity in black women by targeting adolescents: A literature review. Journal of the American Diabetic Association, 94(5), 536-541.

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Schneider, E.G., Leape, L.L., Weissman, U.S., Prana, R.N., Gatsonis, C., & Epstein, A.M. (2001). Racial differences in cardiac revascularization rates: Does Overuse' explain higher rates among white patients? Annals of Internal Medicine, 135, 328-337.

Small, K.M., Wagoner, L.E., Levin, A.M., Kardia, S.L., & Liggett, S.B. (2002). Synergistic polymorphism of U1 and β^sub 2C^ adrenergic receptors and the risk of congestive heart failure. New England Journal of Medicine 347(15), 1135-1142.

Svetkey, L.P., McKeown, S.P., & Wilson, A.F. (1996). Heritability of salt sensitivity in black Americans. Hypertension, 28, 854-858.

Troxel, W.M., Matthews, K.A., Bromberger, J.T., & Sutton- Tyrrell, K. (2003). Chronic stress burden, discrimination, and subclinical carotid artery disease in African American and Caucasian women. Health Psychology, 22(3), 300-309.

Wilhelmsen, L., Rosengren, A., Eriksson, A., & Lappas, G. (2001). Heart failure in the general population of men - morbidity, risk factors, and prognosis. Journal of Internal Medicine, 249, 253-261.

Williams, D.R. (1997). Race and health: Basic questions, emerging directions. Annals of Epidemiology, 7(5), 322-333.

Zevitz, M.E. (2004). Heart failure. Retrieved October 16, 2004, from http:// www.emedicine.com/med/topic 3552. htm

Margaret M. Bolton, MSN, RN, APRN, ANP-C, BC-ADM, is an Adult Nurse Practitioner, Endocrinology Department, Ochsner Clinic Foundation, New Orleans, LA.

Billie Ann Wilson, PhD, APRN, is a Professor and Director, Department of Nursing, Loyola University, New Orleans, LA.

Copyright Anthony J. Jannetti, Inc. Feb 2005

Source: Medsurg Nursing

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