Abstract

Racial and ethnic disparities in cardiovascular diseases (CVDs) remain a significant public health challenge, influenced largely by social determinants of health (SDoH). While genetic predispositions play a minor role, inequities in healthcare access, quality, and outcomes are more prominent. This review highlights the impact of race and ethnicity on cardiovascular risk factors, disease prevalence, and management outcomes. Hypertension, diabetes, obesity, coronary artery disease, and valvular heart diseases exhibit pronounced disparities, with minority populations facing higher disease burdens and suboptimal care. In India, the epidemiological shift toward non-communicable diseases has further exacerbated regional disparities. Culturally tailored interventions, equitable healthcare access, and increased representation in clinical research are essential to mitigate these disparities. Addressing SDoH through policy reforms and community-based initiatives can significantly improve cardiovascular health outcomes across racial and ethnic groups. KEY MESSAGES: • Race and ethnicity are socio-political constructs that significantly influence healthcare disparities, including access, quality, and disease outcomes. • Minority populations, especially Black individuals, have higher hypertension prevalence, poorer blood pressure control, and greater target organ damage due to socioeconomic and environmental factors. • Racial and ethnic minorities, particularly South Asians and African Americans, face a higher burden of obesity and type 2 diabetes, with earlier disease onset and worse metabolic profiles contributing to cardiovascular disease risk. • Despite a high burden of cardiovascular risk factors, racial and ethnic minorities experience disparities in CAD diagnosis, treatment, and outcomes, with lower rates of guideline-directed therapy, reperfusion strategies, and invasive procedures. • Racial and ethnic disparities exist in the diagnosis and treatment of valvular heart diseases, with lower access to surgical and transcatheter interventions.

• 1.   Ostchega Y, Nguyen DT. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017–2018. 2020;(364):8.
• 2.   Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Muntner P. Ethnic Differences in Hypertension Incidence Among Middle-Aged and Older Adults. Hypertension. 2011 Jun 1;57(6):1101–7.
• 3.   Ogunniyi MO, Commodore -Mensah Yvonne, Ferdinand KC. Race, Ethnicity, Hypertension, and Heart Disease. J Am Coll Cardiol. 2021 Dec 14;78(24):2460–70.
• 4.   Ramakrishnan S, Zachariah G, Gupta K, Shivkumar Rao J, Mohanan PP, Venugopal K, et al. Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey. Indian Heart J. 2019 Jul 1;71(4):309–13.
• 5.   Ferdinand KC, Reddy TK, Vo TN. Global interventions in hypertension: new and emerging concepts. Curr Opin Cardiol. 2021 Jul;36(4):436–43.
• 6.   Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, et al. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018 Apr 5;378(14):1291–301.
• 7.   Joseph JJ, Ortiz R, Acharya T, Golden SH, L ópez L, Deedwania P. Cardiovascular Impact of Race and Ethnicity in Patients With Diabetes and Obesity. J Am Coll Cardiol. 2021 Dec 14;78(24):2471–82.
• 8.   National Diabetes Statistics Report 2020. Estimates of diabetes and its burden in the United States. 2020;32.
• 9.   Misra A, Vikram NK. Insulin resistance syndrome (metabolic syndrome) and obesity in Asian Indians: evidence and implications. Nutr Burbank Los Angel Cty Calif. 2004 May;20(5):482–91.
• 10.   Chiu M, Austin PC, Manuel DG, Shah BR, Tu JV. Deriving ethnic-specific BMI cutoff points for assessing diabetes risk. Diabetes Care. 2011 Aug;34(8):1741–8.
• 11.   Shah AD, Kandula NR, Lin F, Allison MA, Carr J, Herrington D, et al. Less favorable body composition and adipokines in South Asians compared with other US ethnic groups: results from the MASALA and MESA studies. Int J Obes 2005. 2016 Apr;40(4):639–45.
• 12.   Tandon N, Anjana RM, Mohan V, Kaur T, Afshin A, Ong K, et al. The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016. Lancet Glob Health. 2018 Dec 1;6(12):e1352–62.
• 13.   Mishriky BM, Powell JR, Wittwer JA, Chu JX, Sewell KA, Wu Q, et al. Do GLP-1RAs and SGLT-2is reduce cardiovascular events in black patients with type 2 diabetes? A systematic review and meta-analysis. Diabetes Obes Metab. 2019 Oct;21(10):2274–83.
• 14.   Singh AK, Singh R. Cardiovascular outcomes with SGLT-2 inhibitors and GLP-1 receptor agonist in Asians with type 2 diabetes: A systematic review and meta-analysis of cardiovascular outcome trials. Diabetes Metab Syndr. 2020 Jul 1;14(4):715–22.
• 15.   Mital R, Bayne J, Rodriguez F, Ovbiagele B, Bhatt DL, Albert MA. Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke. J Am Coll Cardiol. 2021 Dec 14;78(24):2483–92.
• 16.   Preventza O, Critsinelis A, Simpson K, Olive JK, LeMaire SA, Cornwell LD, et al. Sex, Racial, and Ethnic Disparities in U.S. Cardiovascular Trials in More Than 230,000 Patients. Ann Thorac Surg. 2021 Sep;112(3):726–35.
• 17.   Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020 Mar 3;141(9):e139–596.
• 18.   Diez Roux AV, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, et al. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001 Jul 12;345(2):99– 106.
• 19.   Hughes LO, Raval U, Raftery EB. First myocardial infarctions in Asian and white men. BMJ. 1989 May 20;298(6684):1345–50.
• 20.   Jha P, Enas E, Yusuf S. Coronary Artery Disease in Asian Indians: Prevalence and Risk Factors. Asian Am Pac Isl J Health. 1993;1(2):163–75.
• 21.   Prabhakaran D, Singh K, Roth GA, Banerjee A, Pagidipati NJ, Huffman MD. Cardiovascular Diseases in India Compared With the United States. J Am Coll Cardiol. 2018 Jul 3;72(1):79–95.
• 22.   Agarwal A, Jindal D, Ajay VS, Kondal D, Mandal S, Ghosh S, et al. Association between socioeconomic position and cardiovascular disease risk factors in rural north India: The Solan Surveillance Study. PloS One. 2019;14(7):e0217834.
• 23.   Nanna MG, Navar AM, Zakroysky P, Xiang Q, Goldberg AC, Robinson J, et al. Association of Patient Perceptions of Cardiovascular Risk and Beliefs on Statin Drugs With Racial Differences in Statin Use: Insights From the Patient and Provider Assessment of Lipid Management Registry. JAMA Cardiol. 2018 Aug 1;3(8):739– 48.
• 24.   Gamboa CM, Colantonio LD, Brown TM, Carson AP, Safford MM. Race– Sex Differences in Statin Use and Low– Density Lipoprotein Cholesterol Control Among People With Diabetes Mellitus in the Reasons for Geographic and Racial Differences in Stroke Study. J Am Heart Assoc. 6(5):e004264.
• 25.   Sanchez DR, Diez Roux AV, Michos ED, Blumenthal RS, Schreiner PJ, Burke GL, et al. Comparison of the racial/ethnic prevalence of regular aspirin use for the primary prevention of coronary heart disease from the multi-ethnic study of atherosclerosis. Am J Cardiol. 2011 Jan;107(1):41–6.
• 26.   Cavender MA, Rassi AN, Fonarow GC, Cannon CP, Peacock WF, Laskey WK, et al. Relationship of Race/Ethnicity With Door– to– Balloon Time and Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention for ST–Elevation Myocardial Infarction: Findings From Get With the Guidelines–Coronary Artery Disease. Clin Cardiol. 2013 Sep 24;36(12):749–56.
• 27.   Simon S, Ho PM. Ethnic and Racial Disparities in Acute Myocardial Infarction. Curr Cardiol Rep. 2020 Jul 9;22(9):88.
• 28.   Arora S, Stouffer GA, Kucharska– Newton A, Vaduganathan M, Qamar A, Matsushita K, et al. Fifteen– Year Trends in Management and Outcomes of Non–ST–Segment–Elevation Myocardial Infarction Among Black and White Patients: The ARIC Community Surveillance Study, 2000–2014. J Am Heart Assoc. 2018 Oct 2;7(19):e010203.
• 29.   Brister SJ, Hamdulay Z, Verma S, Maganti M, Buchanan MR. Ethnic diversity: South Asian ethnicity is associated with increased coronary artery bypass grafting mortality. J Thorac Cardiovasc Surg. 2007 Jan;133(1):150–4.
• 30.   Lamprea-Montealegre JA, Oyetunji S, Bagur R, Otto CM. Valvular Heart Disease in Relation to Race and Ethnicity: JACC Focus Seminar 4/9. J Am Coll Cardiol. 2021 Dec 14;78(24):2493–504.
• 31.   M T, K S, S A, Q Y, S Y, E L. Prevalence of mitral valve prolapse in ethnic groups. Can J Cardiol [Internet]. 2004 Apr [cited 2022 Jan 12];20(5). Available from: https://pubmed.ncbi.nlm.nih. gov/15100753/
• 32.   Watkins DA, Johnson CO, Colquhoun SM, Karthikeyan G, Beaton A, Bukhman G, et al. Global, Regional, and National Burden of Rheumatic Heart Disease, 1990–2015. N Engl J Med. 2017 Aug 24;377(8):713–22.
• 33.   Otto CM, Nishimura RA, Bonow RO, Carabello BA, III JPE, Gentile F, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2021 Feb 2 [cited 2022 Jan 12]; Available from: https://www.ahajournals.org/doi/ abs/10.1161/CIR.0000000000000923
• 34.   Essien UR, Holmes DN, Jackson LR II, Fonarow GC, Mahaffey KW, Reiffel JA, et al. Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation: Findings From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II. JAMA Cardiol. 2018 Dec 1;3(12):1174–82.
• 35.   Alqahtani F, Aljohani S, Amin AH, Al-Hijji M, Ali OO, Holmes DR, et al. Effect of Race on the Incidence of Aortic Stenosis and Outcomes of Aortic Valve Replacement in the United States. Mayo Clin Proc. 2018 May;93(5):607–17.
• 36.   Alkhouli M, Holmes DR, Carroll JD, Li Z, Inohara T, Kosinski AS, et al. Racial Disparities in the Utilization and Outcomes of TAVR. JACC Cardiovasc Interv. 2019 May 27;12(10):936–48.
• 37.   Bahrami H, Kronmal R, Bluemke DA, Olson J, Shea S, Liu K, et al. Differences in the incidence of congestive heart failure by ethnicity: the multi-ethnic study of atherosclerosis. Arch Intern Med. 2008 Oct 27;168(19):2138–45.
• 38.   Nayak A, Hicks AJ, Morris AA. Understanding the Complexity of Heart Failure Risk and Treatment in Black Patients. Circ Heart Fail. 2020 Aug;13(8):e007264.
• 39.   Health Disparities in Advanced Heart Failure Treatment: The Intersection of Race and Sex | Cardiology | JAMA Network Open | JAMA Network [Internet]. [cited 2022 Jan 25]. Available from: https://jamanetwork. c o m / j o u r n a l s / j a m a n e t w o r k o p e n / fullarticle/2768392
• 40.   Ileana L. Piña MD, Shirin Jimenez MD, Eldrin F. Lewis MD, Alanna A. Morris MD, Anekwe Onwuanyi MD, Edlira Tam DO, et al. Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9. J Am Coll Cardiol [Internet]. 2021 Dec 21 [cited 2022 Jan 12]; Available from: https:// www.jacc.org/doi/10.1016/j.jacc.2021.06.058
• 41.   Rathore SS, Masoudi FA, Wang Y, Curtis JP, Foody JM, Havranek EP, et al. Socioeconomic status, treatment, and outcomes among elderly patients hospitalized with heart failure: Findings from the National Heart Failure Project. Am Heart J. 2006 Aug 1;152(2):371–8.
• 42.   Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med 1982. 2018 Feb;199:219–29.
• 43.   Zhang J, Johnsen SP, Guo Y, Lip GYH. Epidemiology of Atrial Fibrillation: Geographic/Ecological Risk Factors, Age, Sex, Genetics. Card Electrophysiol Clin. 2021 Mar;13(1):1–23.
• 44.   Norby FL, Benjamin EJ, Alonso A, Chugh SS. Racial and Ethnic Considerations in Patients With Atrial Fibrillation: JACC Focus Seminar 5/9. J Am Coll Cardiol. 2021 Dec 21;78(25):2563–72.
• 45.   Piccini JP, Hammill BG, Sinner MF, Jensen PN, Hernandez AF, Heckbert SR, et al. Incidence and prevalence of atrial fibrillation and associated mortality among Medicare beneficiaries, 1993-2007. Circ Cardiovasc Qual Outcomes. 2012 Jan;5(1):85–93.
• 46.   Khalid U, Marzec LN, Mantini N, Manson SM, Doros G, Cannon CP, et al. Treatment of AF in American Indians and Alaska Natives: Insights From the NCDR PINNACLE-AF Registry. J Am Coll Cardiol. 2020 Jun 2;75(21):2749–50.
• 47.   Chakravarthy MV, Booth FW. Eating, exercise, and “thrifty” genotypes: connecting the dots toward an evolutionary understanding of modern chronic diseases. J Appl Physiol Bethesda Md 1985. 2004 Jan;96(1):3–10.
• 48.   CARDIoGRAM plus C4D Consortium, Deloukas P, Kanoni S, Willenborg C, Farrall M, Assimes TL, et al. Large-scale association analysis identifies new risk loci for coronary artery disease. Nat Genet. 2013 Jan;45(1):25–33.
• 49.   Ehret GB, Munroe PB, Rice KM, Bochud M, Johnson AD, Chasman DI, et al. Genetic variants in novel pathways influence blood pressure and cardiovascular disease risk. Nature. 2011 Oct;478(7367):103–9.
• 50.   Barlassina C, Schork NJ, Manunta P, Citterio L, Sciarrone M, Lanella G, et al. Synergistic effect of α-adducin and ACE genes causes blood pressure changes with body sodium and volume expansion. Kidney Int. 2000 Mar 1;57(3):1083–90.
• 51.   Ol KK, Agachan B, Gormus U, Toptas B, Isbir T. Cox-2 gene polymorphism and IL-6 levels in coronary artery disease. Genet Mol Res GMR. 2011 May 10;10(2):810–6.

Data Sharing Statement

Funding