Race cannot be used to predict heart disease, scientists say
Doctors have long relied on some key patient characteristics to assess the risk of heart attack or stroke, using a calculus that takes into account blood pressure, cholesterol, smoking and diabetes status, as well as demographics: age, gender and race.
Now the American Heart Association is taking race out of the equation.
The revision of the commonly used heart risk algorithm is a recognition that, unlike gender or age, racial identification is not in itself a biological risk factor.
The scientists who adapted the algorithm decided from the start that race itself had no place in clinical tools used to guide medical decision-making, even though race could serve as a proxy for certain social conditions, genetic predisposition, or exposure to the disease. environment that increase the risk of cardiovascular disease. disease.
The revision comes amid growing concerns about health care equity and racial bias within the U.S. health care system, and is part of a broader trend to remove race from a variety of clinical algorithms.
“We shouldn’t use race to inform whether someone gets treatment or not,” says Dr. Sadiya Khan, a preventive cardiologist at Northwestern University Feinberg School of Medicine who chaired the statement writing committee for the American Heart Association, or AHA
The statement was published on Friday in the association magazine Circulation. An online calculator using the new algorithm, called PREVENT, is still in development.
“Race is a social construct,” said Dr. Khan, adding that including race in clinical comparisons “can cause significant harm by implying that it is a biological predictor.”
That doesn’t mean Black Americans aren’t at greater risk of dying from cardiovascular disease than white Americans, she said. That’s true, and the life expectancy of black Americans is also shorter, she added.
But race is used in algorithms as a proxy for a range of factors that work against Black Americans, Dr. Khan said. It is not clear to scientists what all those risks are. If they were better understood, “we could address them and work to change them,” she said.
Cardiac risk assessment has also improved in several other important ways. It can be used by people aged 30 and over, unlike the previous algorithm, which was only valid for people aged 40 and over, and estimates total cardiovascular risk over 10 and 30 years.
The assessment has been redesigned for the first time to estimate an individual’s risk of developing heart failure, not just heart attack and stroke. This is important because heart failure has increased in recent years due to an aging population and the high prevalence of obesity. The condition can lead to a serious deterioration in quality of life.
The new calculator also takes kidney function into account for the first time when predicting risk, because kidney disease puts people at higher risk for heart disease, heart attacks, heart failure and stroke.
In recent years, there has been increasing recognition of the strong link between cardiovascular disease, kidney disease and metabolic diseases (including type 2 diabetes and obesity). Last month, the association’s scientific advisors defined a new condition called cardiovascular-renal-metabolic syndrome, or CKM
“CKM is associated with significant premature mortality, primarily due to cardiovascular disease,” said Dr. Chiadi Ndumele, a cardiologist at Johns Hopkins Medicine and author of the new scientific statement.
“It is disproportionately present when there are adverse social determinants of health,” he said, including “the social context in which we eat, work, learn and play.”
The new equation also provides options to include a measure of blood sugar control, called hemoglobin A1C, in people with type 2 diabetes, and to include a factor called the Social Deprivation Index, which measures poverty, unemployment, education and includes other factors.
The changes are “great news,” said Dr. David S. Jones, a psychiatrist and professor of the history of medicine at Harvard, who wrote a paper on the use of race in numerous medical decision-making algorithms which was published in 2020 in the New England Journal of Medicine.
The article described how race has been used in a wide range of clinical algorithms relied on to make medical judgments about conditions as diverse as urinary tract infections, vaginal birth after cesarean sections, breast cancer, lung function and kidney function.
“It is immensely satisfying to see how medical thinking on this topic has changed over the past three to five years,” said Dr. Jones.
While racial disparities exist on many health measures, scientists need to conduct research to understand exactly what causes the disparities, he said, adding: “You can’t just divide the world into black and white people and say all white people understand this and all black people get that.
However, implementing the changes could be difficult, he said.
Two years ago, a scientific task force from the National Kidney Foundation and American Society of Nephrology called for ditching a measure of kidney function that adjusted results by race, often making black patients appear less sick than they are and leading to delays in treatment. treatment led.
Within 18 months, about 65 percent of all laboratory facilities had adopted the new approach, said Dr. Neil Powe, chief of medicine at Zuckerberg San Francisco General Hospital and professor of medicine at the University of California, San Francisco.
Dr. Powe said he shared a concern expressed by the authors of the AHA’s scientific statement: What exactly underlies racial health disparities?
“I have often said that we need to do more research to understand what race means and what its replacement is,” said Dr. Power.
Many physicians do not know whether and to what extent their patients experience social stressors that affect their health. For example, research on maternal mortality has shown that wealth and higher education do not offset the adverse health consequences associated with being black in America.
Although the wealthiest mothers and their babies are most likely to survive the year after giving birth, a study in California found that the same was not true for black women: the wealthiest black mothers and their babies are twice as likely to die, compared to the wealthiest white mothers. mothers and their babies.