Racial and ethnic disparities in arrhythmia care: A call for action
Introduction
Racial, cultural, and socioeconomic factors drive the disparities in the diagnosis, management, outcomes, and study of diseases. Among racial and ethnic minority populations, those of Asian, Native American, and Hispanic origin are grossly underrepresented in clinical studies. Most of the clinical research and data regarding the various aspects of a disease are limited to racial groups of Western European origin. In the multiethnic and multiracial US, African American or Black individuals are the next most studied racial and ethnic minority group. The overall cost of racial and ethnic disparities resulting in health care inequalities and premature death is estimated to be around $1.24 trillion.1
Despite advances in the field of cardiac electrophysiology, significant racial and ethnic disparities exist. Compared with White individuals, Black individuals with cardiovascular disease generally have a higher burden of comorbidities and have an increased risk of adverse arrhythmia-related outcomes.2, 3, 4 Understanding varied risk factor profiles and ways to improve clinical outcomes is critical to mitigating health care disparities and their resultant socioeconomic burden. The copious number of publications documenting the pervasiveness of these disparities warrants immediate attention and a call to action. Medical societies, professionals, researchers, governmental agencies, communities that include predominantly racial and ethnic minorities, and faith leaders should be galvanized and coordinate efforts with clinicians to affect a salutary outcome. Despite having the most advanced and sophisticated health care system, clinical outcomes of various diseases, including all aspects of cardiovascular disease, differ across racial and ethnic groups in the US. The present paper highlights the racial and ethnic differences in arrhythmia management and outcomes between White and Black populations and outlines recommendations that will assist the Heart Rhythm Society in achieving its goal of equitable care in the management of heart rhythm disturbances in North America (Figure 1).
Section snippets
Atrial fibrillation
Epidemiologic data relevant to atrial fibrillation (AF) are by far more extensive than those for any other cardiac arrhythmias, likely due to the global burden of AF. However, data on AF among various racial and ethnic populations including American Indian or Alaska Native, Native Hawaiian, or other Pacific Islander populations are limited. Often, differences in study design, access to care, and AF detection methods preclude direct comparisons across various racial and ethnic groups.
Black
Pharmacotherapy for cardiac arrhythmias
Racial differences exist in pharmacologic and procedural rhythm control in Black individuals compared with White individuals. Black individuals are more likely to undergo a rate control strategy (and less likely a rhythm control approach) for AF than White individuals.47 In the subgroup analysis of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study, Black individuals, in addition to being underrepresented, had a similar overall survival between rate and rhythm
Racial and ethnic disparities in research
Research aimed at elucidating the etiology of racial inequities in arrhythmia care has been limited but suggests that causes are likely multifactorial in nature, including patient mistrust of research, poor clinician–patient communication, implicit bias, disproportionate prevalence of limited health literacy, decreased access to health care, and health system–related factors. The factors that contribute to racial inequities may vary for different racial and ethnic groups.77
Social determinants of health
Social determinants of health (SDOH) represent the influence of circumstances in which individuals are born, live, work, and age. Black individuals constitute the oldest nonnative population in the US, yet their markers of socioeconomic position (education, valued work, social connections, food, and financial security) remain below those of many other racial groups. More than 30% of Black individuals in the US are living below the poverty line. The mean life expectancy is 3.4 years less with
Representation of racial and ethnic minorities in clinical trials and arrhythmia research
Most clinical trials of cardiovascular disease and arrhythmia research predominantly enroll White individuals and have low enrollments of individuals from Hispanic/Latinx, Black/African American, American Indian/Alaska Native, Hawaiian/Pacific Islander, and some Asian populations. Because safety and effectiveness may vary in different populations, the lack of racial and ethnic diversity in clinical trial enrollment compromises the health care that can be delivered to those who are excluded.
Implicit bias
The purpose of clinical practice guidelines informed by clinical trials and registries is to understand various disease substrates and study the effects of new treatment interventions and outcomes in an attempt to offer the best possible treatment regardless of sex, race, or ethnicity. Studies have shown that non-Hispanic White clinicians may perceive Black individuals as nonadherent—a perception often influenced by their socioeconomic position and reflecting implicit bias, which is a term used
Intersocietal collaboration
The Heart Rhythm Society (HRS) is a 501c3 international nonprofit organization founded in 1979 with a mission to improve the care of all patients by promoting research, education, and optimal health care policies and standards. The Heart Rhythm Society is a leading resource on cardiac pacing and electrophysiology. Its worldwide reach and representation in more than 90 countries should afford its credibility and influence in the pursuit of diversity, equity, and inclusion in all organizational
Conclusion
Racial and ethnic minority individuals face significant inequities in arrhythmia care. Differences in the arrhythmogenic substrate, comorbidities, management approaches, SDOH, and access to health care as well as structural racism are important contributing factors. A systematic approach to improve access to health care among racial and ethnic groups that have been economically and socially marginalized, promote disease awareness, provide patient education to improve health literacy, optimize
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Cited by (6)
Racial and Ethnic Disparities in Patients Who Underwent Leadless Pacemaker Implantation
2023, American Journal of CardiologyThe Impact of Age on the Epidemiology and Cost of Atrial Fibrillation Hospitalizations
2023, American Journal of CardiologyTrends and disparities in ventricular tachycardia mortality in the United States
2023, Journal of Cardiovascular Electrophysiology
Funding Sources: The authors have no funding sources to disclose.
Disclosures: The authors have no conflicts of interest to disclose.
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Kevin L. Thomas, MD, FHRS, FACC, and Jalaj Garg, MD, FACC, FESC, are co-first authors and have contributed equally to the manuscript preparation.