Ratnasiri 1

THE EXISTING DISPARITIES

WITHIN CARDIOVASCULAR
DISEASE RATES IN THE UNITED
STATES
A Systematic Literature Review

Buddhika Ratnasiri

University of California, Berkeley

 Ratnasiri 2

Abstract

Background – Cardiovascular disease is the leading cause of death for men and women in the

U.S and kills hundreds of thousands of individuals every year. This review examines the

disparities that exist and how certain groups and categories of individuals (age, gender,

race/ethnicity, and socioeconomic status) develop cardiovascular disease at differing rates.

Methods – A systematic literature review was performed, incorporating many empirical studies

on cardiovascular disease and how cardiovascular disease affects certain populations at a greater

effect compared to others. Data was collected from different primary research articles published

in established research journals on cardiovascular disease such as Circulation and JAMA.

Results – Through the various notable primary research articles analyzed disparities related to

age, gender, race/ethnicity, and socioeconomic class were notable. It was found that the

population in both males and females 65 years or older had significantly higher rates of heart

disease, women suffered from treatment delays for acute myocardial infarction due to gender

inequalities, Black men and women were significantly more likely to die from cardiovascular

disease than White men and women, and lower socioeconomic status was associated with higher

mortality rates from cardiovascular disease.

Conclusions – After thorough analysis of multiple primary research articles, there is sufficient

evidence to conclude that disparities continue to exist and impact certain populations in the

United States based on age, gender, race/ethnicity, and socioeconomic class. Therefore, more

research needs to be done looking into the reasons as to why these disparities exist and the

impact the social environment has on an individual’s health.

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Introduction

Cardiovascular disease is the leading cause of death in the world and the mortality rate

from cardiovascular disease is only expected to grow in the current conditions (Fig. 1).1 Killing

hundreds of thousands of people every year, cardiovascular disease was recognized as a public

health threat by the United Nations World Health Organization (WHO) in 2011, who were

committed towards fighting heart disease.2 Communicable diseases, such as tuberculosis and

cholera, are still a major issue in developing countries, but non-communicable diseases, such as

cardiovascular disease and cancer, are rising in incidence.

Cardiovascular disease, which is used interchangeably with heart disease, is a serious

condition where arteries or blood vessels are narrowed or blocked due to plaque buildup, thus

impacting the functioning of other organs beside the heart. The constriction of these blood-

carrying vessels can lead to a host of problems; heart attacks, cardiac dysrhythmia, angina or

stroke are more likely to follow and cause death.3 Cardiovascular disease is categorized under

non-communicable diseases because it cannot be transferred from one person to another and is

characterized by their long duration and slow progression.

It would be helpful for a review to be done about current research because it is vital to

identify risk factors that are involved in cardiovascular disease in order to help individuals lower

their risk for acquiring this deadly disease. For example, major risk factors for cardiovascular

disease are obesity and sedentary activity, but prevention techniques, such as better nutrition and

increased physical activity, can help reduce this risk. This review can assist healthcare

professionals in advising patients on risk factors involved in developing cardiovascular disease

as well as warn these individuals about the disparities that exist within cardiovascular disease.

For example, certain groups and categories of individuals (age, gender, race/ethnicity and
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socioeconomic status) have differing rates of the disease. With this information, healthcare

professionals and even policy makers can help allocate more resources and focus toward higher

quality care to help these individuals live healthier and disease-free lives. Even though

cardiovascular disease presents itself as a global issue, this review will focus on the prevalence

and incidence of cardiovascular disease in the United States, a country that has an extremely

diverse population of individuals, which may account for why see disparities in rates of

cardiovascular disease.

The issue of cardiovascular disease is at the forefront of research in developing countries

and is the leading cause of death for men and women in the U.S, killing hundreds of thousands of

individuals every year, but disparities exist in that certain groups of individuals develop

cardiovascular disease at higher rates than others; therefore it is essential to further research how

risk factors are distributed in populations and what methods can be taken to reduce these

disparities as well as the risk of developing cardiovascular disease. This review will hopefully

illuminate what disparities exist and how certain groups and categories of individuals (age,

gender, race/ethnicity, and socioeconomic status) develop cardiovascular disease at differing

rates in order to enlighten the general public, healthcare professionals and policy makers on the

risks of cardiovascular disease. With this knowledge, we can invest more time and resources

with the primary goal of eliminating disparities in rates of cardiovascular disease, thus promoting

health equity.
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Figure 1: Annual number of deaths by cause in the United States, 2016

Source: Our World in Data, 2016, Institute of Health Metrics and Evaluation, Figure No. 1

Burden of Cardiovascular Disease in the United States

Cardiovascular disease is currently responsible for killing 610,000 people every year,

meaning 1 out of every 4 deaths in the United States is due to cardiovascular disease.4 The

significant rates in mortality from cardiovascular disease are not only responsible for the

priceless loss of human lives but also puts a huge burden on the healthcare system, resulting in

billions of dollars in cardiovascular disease prevention and treatment; in 2006, cardiovascular

disease was directly and indirectly involved in around $400 billion in annual costs.5 Although

billions of dollars are invested into cardiovascular disease annually, there are not enough

resources and attention being put into the cause, which would effectively reduce cardiovascular
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disease mortality. It is easy to quantify the loss of disability adjusted life years (DALYs) that

cardiovascular disease is responsible for, but the impact the loss of a loved one has on families is

unquantifiable beyond the loss in income. National trends in cardiovascular disease have shown

that there has been a decline in cardiovascular disease mortality over the last decade; however,

this decline has slowed down, meaning that though rates of cardiovascular disease mortality have

been decreasing, they have been decreasing at a slower rate in recent years. From 2000 to 2011,

there was a decline of 3.69% and 3.98% in cardiovascular disease mortality in men and women

respectively, but only 0.23% and 1.17% in men and women respectively from 2011 to 2014.6 As

a result, it is important to realize that the deceleration in the decline of cardiovascular disease

rates is a worrying sign and implies that more must be done to address why cardiovascular

mortality continues to plague our nation.

Disparities in Cardiovascular Disease

Cardiovascular disease can affect individuals of all ages and race/ethnicities, but

disparities occur where certain groups of individuals are at a higher risk than others. Disparities

that we see with regards to cardiovascular disease lie within age groups, gender, race/ethnicity

and socioeconomic status. This review will further explore the differences in these disparities

and how the risk of developing cardiovascular disease is impacted by these categories.

Age Group

With the baby boomer population not getting any younger, the United States healthcare

system will be heavily impacted by the increasing number of elderly people in the near future.
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Age is often associated with weakness, and the elderly are at a significantly higher risk than

other ages at acquiring cardiovascular disease and conditions, such as heart attacks, hypertension

and stroke. An advanced age is one of the most powerful risk factors for cardiovascular disease

and as seen in Table 1, rates of cardiovascular disease are significantly higher per 100,000

population in both males and females that are 65 years or older than rates in the general

population. Among elderly individuals (aged 65 years or older), heart disease was over 1.6 times

as important as cancer, more than 4 times as important than cerebrovascular disease and more

than 10 times as important as pulmonary disease.7 Therefore, disparities in age are significant,

and even though age is a non-modifiable risk factor, it is important to be aware that seniors are

experiencing significantly higher rates of cardiovascular disease in order to allocate more

resources to treating the up-and-coming elderly population that is comprised of the innumerable

baby boomer generation.

Table 1. Death Rates by Leading Causes by Gender and Race, 1980 – 1995 (Per 100,000)

Source: Demographics and Cardiology, 1950-2050, 2000, Table No. 5

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Gender

Recently, the presence of disparities in gender has become an increasingly important

topic that was wrongly disregarded in the past, as women do not get the same resources,

employment, salary and care that men do. Although many previous studies have found an inverse

relationship between socioeconomic status and the risk of cardiovascular disease, few, if any,

have examined the gender differences in the relationship between socioeconomic status and

cardiovascular disease.8 Women often face many barriers to treatment for CVD, including social

deprivation and poor access to healthcare, and these issues manifest themselves in disparities in

the risk of developing cardiovascular disease. When looking at individuals at the lowest level of

education, women had a 24% higher risk of coronary heart disease compared to men.9 As seen in

Figure 2, women have a higher relative risk when controlling for education, area, occupation and

income. This finding may be partially explained by the fact that treatment delays for acute

myocardial infarction occur more frequently in women than men which can lead to poorer health

outcomes for women with myocardial infarction.8 Likewise, women with a lower socioeconomic

status are less likely to receive preventive treatments for cardiovascular disease than men of

similar socioeconomic status.7 Therefore, when looking at the relative risks in women compared

to men, we can see that disparities in gender exist among rates of cardiovascular disease and can

be partially explained by the inferior treatment of women with regards to income, employment

and even medical treatment.

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Figure 2: Age-adjusted pooled relative risk of cardiovascular disease outcomes associated with
lowest versus highest socioeconomic status in men and women.
Source: Sex differences in the relationship between socioeconomic status and cardiovascular
disease: a systematic review and meta-analysis, 2016, Figure No. 2

Race/Ethnicity

Disparities in race/ethnicities with respect to cardiovascular disease rates and

cardiovascular disease mortality is a very controversial topic, as previous research has found that

minorities are more likely to acquire diseases such as cardiovascular disease.10 In a study

conducted by the Centers for Disease Control and Prevention through the National Health and
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Nutrition Examination Survey (NHANES), a highly regarded program of epidemiological

studies, it was found that 25% of black men and 12% of black women were considered at risk of

fatal cardiovascular disease compared to only 10% of White men and 3% of White women.11

This gap in fatal cardiovascular disease risk demonstrates that there is an issue with how the

black population develops cardiovascular disease compared to how the white population

develops this disease. Risk factors, including high blood pressure, high serum cholesterol,

tobacco smoking and diabetes mellitus, were adjusted for in order to make estimates

representative of the national population. Targeting diabetes mellitus through a prevention

program was found to have the largest impact on cardiovascular disease rates, reducing the

disparity between black and White individuals by 9% in men and 13% in women.8 Therefore, it

is essential to understand why Black individuals acquire higher risk of developing fatal

cardiovascular disease than White individuals, and what social factors are responsible for this

gaping disparity.

Table 2: Proportion of Population and Proportion of Fatal Cardiovascular Disease Events

Occurring Among High-Risk Individuals by Sex and Race

Source: Sick Populations and Sick Subpopulations: Reducing Disparities in Cardiovascular

Disease Between Blacks and Whites in the United States, 2016, Table No. 2
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Socioeconomic Status

Low socioeconomic status has long been tied to inequalities in the acquisition of

resources, income, and necessary medical treatment, all which influence an individual’s health.

In the population in Alameda Country, which contains a diverse population, in terms of age,

race/ethnicity and socioeconomic status. The father’s education, the respondent’s education and

an estimate of household income were found to contribute to cardiovascular disease mortality

among individuals in Alameda County. The use of confounder adjusted models including age,

race/ethnicity and marital status accounted for differences in these characteristics among the

population of Alameda County. The bivariate hazards model, as seen in Table 3, shows that for

men and women at a larger disadvantage, which is characterized by a higher CSD measure, had a

higher hazard ratio in cardiovascular disease mortality.12 Socioeconomic status can influence

many factors in an individual’s life that can determine how healthy they are including access to

healthcare and educational attainment. Education, in and of itself, can be a strong predictor of

good health. Education has a significant impact on individual behavior through critical thinking

and application of previously acquired knowledge which can lead to financial stability and a

positive mindset on life that all contribute significantly to good health.13 Likewise,

socioeconomic status can also influence an individual’s diet, as fresh, healthy foods are often far

more expensive than processed, unhealthy foods. There is a clear nutritional inequality that

promotes cardiovascular disease development among individuals of low socioeconomic status

that strengthens the association between socioeconomic status and rates of cardiovascular

disease.8 Therefore, it is important to address the fact that individuals of low economic status

often cannot obtain the resources and high-quality care they need to maintain good health and

how social factors can influence health outcomes.

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Table 3: Bivariate Hazards Model of Cardiovascular Disease by Gender in Alameda County

Sample

Source: Cumulative socioeconomic disadvantage and cardiovascular disease mortality in the

Alameda County Study 1965 to 2000, 2015, Table No. 3

Prevention

Even though non-modifiable risk factors such as age, race/ethnicity, gender and

socioeconomic status cannot be changed or are incredibly difficult to change, there are still

effective measures that can be taken in order to reduce an individual’s risk of developing

cardiovascular disease. Modifiable risk factors, factors that can be changed through an

individual’s lifestyle, include nutrition, physical activity and individual behavior, all of which

can significantly affect the risk of developing cardiovascular disease.14

Nutrition is not only important to decrease one’s risk of developing heart disease but also

is essential in maintaining good health and well-being. A healthy diet requires the right amounts

of fruits, vegetables, grains, protein and dairy. Although eating sugary and fatty foods is

unavoidable, it is important to limit these unhealthy foods as much as possible. Sugary foods are

a significant factor in developing diabetes while fatty foods are known to increase cholesterol

levels, arterial blood pressure, triglyceride concentrations and lead to increased rates of obesity.
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A Mediterranean diet, consisting of larger portions of fruit, vegetables, legumes and fish, was

associated with a 10% reduction in cardiovascular disease risk and was significantly associated

with positive health outcomes and lead to a better quality of life.15 As a result, nutrition is a vital

factor in maintain good overall health and can significantly reduce an individual’s risk of

developing cardiovascular disease.

Physical activity, similar to nutrition, is essential in reducing the risk of not only

cardiovascular disease but other diseases as well. The recommended guidelines for physical

activity are around 150 minutes a week and significantly less would be considered sedentary. A

sedentary lifestyle is associated with higher levels of saturated fatty acids which are the main

culprits for arterial plaque buildup. Based on a study of nearly 900,000 participants, which

supports the external validity of a study, physical activity was associated with a risk reduction of

35%.16 These findings displayed statistical significance and demonstrated that regular physical

activity was associated with a reduced risk of cardiovascular disease mortality.

Individual behaviors such as smoking and alcohol consumption are equally as vital in

order to prevent the onset of many diseases, including cardiovascular disease. Smoking and

alcohol consumption, which can also be categorized as poor coping behaviors due to stress, can

lead to higher blood pressure which can damage arterial walls. Without the smooth flow of blood

through arteries, the heart may not be able to function to its maximum potential which can lead

to risk of cardiovascular disease. After adjusting for other comorbities such as arterial blood

pressure, cholesterol concentration and triglyceride concentration, female smokers had a relative

risk of 2.24 and male smokers 1.43 relative to non-smokers (1.00).17 This statistically significant

result demonstrated that female smokers have a 124% higher chance of myocardial infarction
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while male smokers have a 43% higher chance of myocardial infarction, illustrating the effect of

smoking on rates of cardiovascular disease. Therefore, it is important to recognize that even

though disparities may exist for non-modifiable risk factors such as age, race/ethnicity, gender,

and socioeconomic class, there are still many preventive actions an individual can take in order

to decrease his/her risk of developing cardiovascular disease.

Conclusion

Cardiovascular research is important now more than ever as hundreds of thousands of

people die each year. Although it is a shame so many innocent lives were lost due to this deadly

disease, it is important to focus on the future and how we should approach cardiovascular

disease. In a study done looking at how cardiovascular disease mortality and disparities would

progress until 2030, Pearson-Stuttard developed a model based off data from the National Vital

Statistics System Surveillance, Epidemiology and End Results (1979-2012) that was stratified by

age, sex and race. Even though the American Heart Association has developed models

incorporating the expected population growth and aging, they haven’t taken into account the

recent declining trends in cardiovascular disease mortality rates. The predicted model concluded

that total U.S. coronary deaths are expected to decline, but the health disparities are expected to

remain despite some improvement.18 Disparities in cardiovascular disease will continue to be an

issue and will require a larger investment of time and resources in order to reduce the disparities

we see in certain groups of individuals.

One aspect of this issue that needs more attention is an environment influences an

individual’s health. Past research has singled in on how individual behaviors can determine
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health outcomes, such as how smoking influences the risk of myocardial infarction, but little

research has been done on how the social environment can contribute to disease. For example, in

the current healthcare system, doctors focus on the biomedical model, which attributes morbidity

and mortality to molecular-level pathogens brought about by individual lifestyles, behaviors,

hereditary biology, or genetics where we should also be considering the ecologic model which

focuses on how the relationship between an individual and his/her environment can influence

health outcomes.19 The policies/laws governing an area, level of crime in an area, few accessible

healthy grocery stores or even minimal social neighborhood interaction can contribute to poor

health outcomes in individuals. For example, one major risk factor that can contribute to

increased rates of cardiovascular disease is chronic stress. Chronic stress, which can result from

job insecurity, poverty or relationship trouble, can contribute to excess plaque buildup in arteries

which can directly increase rates of heart attacks. Poverty and low income, factors that are

overwhelmingly designated to minorities and immigrants, contribute to disparities that exist

between different races/ethnicities. Chronic stress through poverty could be alleviated by

reducing discrimination and providing more opportunities to low-income individuals. As a result,

it is important to realize that the risk of developing diseases such as cardiovascular disease can

also be influenced by an individual’s social environment and more research must be done in

order to whole-heartedly tackle why disparities occur.

Therefore, it is essential to further research how risk factors are distributed in populations

and what methods can be best taken to reduce these disparities as well as the risk of developing

cardiovascular disease. If sufficient action is not taken, cardiovascular disease will continue to

remain the leading cause of death for men and women in the United States and disparities will
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continue to exist and detrimentally impact certain populations based on age, race/ethnicity,

gender, and socioeconomic class.

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