Addressing inequalities in cardiovascular health remains an urgent priority

Despite advances in almost every single aspect of the management of cardiovascular diseases (CVDs), they remain the leading cause of death globally, with >17 million premature deaths per year [1]. Many cases of CVD can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, and harmful use of alcohol. However, accumulating evidence supports the understanding that persistent inequalities in our social environments shape our personal lifestyle choices that profoundly influence CVD risk factors [2]. Indicatively, in England, CVDs are among the largest contributors to health inequalities, responsible for 20% of the life expectancy gap between the most and least deprived communities, with people from South Asian and Black groups having the highest risk of CVD, and in the USA, CVD mortality at all ages tends to be highest among black people [1].

Although there are such inequalities between population groups within countries, it should be noted that there are also inequities in how cardiovascular morbidity and mortality are distributed geographically at a global, national, and regional level [1, 2]. These inequities become even clearer when comparing High- to Low- and Middle-Income Countries (LMICs), especially considering how profoundly education, income or aggregation of assets, and household facilities, known as the Wealth index, influence the CVD risk factors [2].

Persistent inequalities in cardiovascular disease

We have been reminded of such health inequalities in CVD all too often in recent years.

The COVID-19 pandemic served as a stark reminder of how social and economic inequalities heavily influence health outcomes. The preexisting high global prevalence of CVD worsened the COVID-19 pandemic by draining valuable resources and serving as a confounding risk for adverse outcomes. These risks were disproportionately borne by groups that were most vulnerable, including by factors such as gender, economic disadvantage, and ethnic minority status [3].

Earlier this year, Olympic sprint champion Tori Bowie’s death from eclampsia during childbirth made headlines globally and resurfaced into the public conversation an uncomfortable fact: that black women are a lot more likely than their white counterparts to die from CVD and pregnancy-related causes in the US, as in several other white-majority countries around the world [4]. The reasons for these disparities are multifaceted.

For example, research from the US has shown that despite women being at lower risk than men of developing acute coronary syndrome, they remain undertreated with evidence-based therapies with consequently increased risk of complications [5]. The need to better understand and address differences in short- and long-term outcomes between women and men in the setting of CVD remains largely unmet [6].

However, biological sex differences are not enough to explain disparities in outcomes. In research using primary care data from the UK, it has been demonstrated that despite a lack of variation in antihypertensive initiation by ethnicity, subsequent blood pressure control is notably lower among the people of African/African Caribbean ethnicity, potentially associated with being less likely to remain on regular treatment [7]. Accumulating evidence from studies such as this have been added to calls on reviewing the inclusion of race and ethnicity in CVD management guidelines. There are inconsistencies in the inclusion of race in UK guidelines and a real concern that using a poorly defined notion of self-assigned race in treatment decisions without context allows a historic perspective of racial pathology to persist that lacks a robust scientific evidence base [8].

This intersectionality between factors such as gender, ethnicity and CVD outcomes is further compounded by socioeconomic determinants.

There have been calls to see the current cost-of-living crisis under a lens of a public health issue, as poverty and economic inequality are well-evidenced risk factors for CVD [9]. For example, lacking the resources to use heating means living in cold and damp conditions, which, in turn, increases the risk of myocardial infarction and stroke. Recent research has shed light on the fact that socioeconomic status remains a largely unrecognized risk factor when it comes to the primary prevention of CVD [9]. Risk scores that exclude socioeconomic deprivation as a covariate under- and overestimate the risk in the most and least deprived individuals, respectively. Thus, it is important to incorporate socioeconomic deprivation status in risk estimation systems to ultimately reduce inequalities in health care provision for CVD [9].

Focusing on solutions

It is evident that avoidable health inequalities remain a leading factor influencing CVD outcomes, as well as access to preventative and therapeutic interventions. Coordinated action to address such inequalities in the coming years will be key.

This issue is brought to the spotlight during this year’s World Healthy Life Week, taking place between Monday, 30 October, and Sunday, 5 November 2023. The Week is an international event, now in its fourth year. It is about taking a holistic view of our heart health to promote a healthy life for all, and is a partnership between the Healthy Heart Trust (established in 1996 as the Cardiovascular Research Trust) and the Fellowship of Postgraduate Medicine [10].

The theme for this year’s World Healthy Life Week is ‘Health Inequalities: Towards Cardiovascular Health Equity’. It is a platform to [10]:

• Exchange knowledge on the evidence of promoting cardiovascular health and prevention through seminars and partnerships;

• Inspire people to take positive action to protect their health and that of their families and communities through events and accessible content;

• Educate decision-makers to implement health-promoting policies and measures;

• Enable a dialogue between the arts and cardiovascular health through the ‘Art of the Heart’ annual international awards.

A series of international webinars is at the heart of the Week’s activities to enable the exchange of knowledge on the evidence of promoting health and preventing illness and inspire people and decision-makers to take positive action to protect cardiovascular health. In 2023, the focus is on key topics related to cardiovascular health inequalities: women’s cardiovascular health, racial equality and hypertension, and economic inequality and CVD.

Through drawing attention, during World Healthy Life Week, to the critical matter of health inequalities, there is a hope that greater coordinated action can follow. There are several solutions that have been articulated already but remain underdeveloped at the stage of implementation. It will be important for webinars offering knowledge exchange to discuss and offer solutions to health professionals and policy makers alike.

As a starting point, local and national prevention efforts are urgently needed, targeting both individuals and whole communities. Programmes should focus on the risk and protective factors where evidence shows the influence of gender, racial, and socioeconomic inequalities is greatest [2].

A lot of the solutions on how preventative interventions can best be implemented will come from working in equal partnership between health professionals and communities. For example, on the matter of addressing gender and racial inequalities, addressing conscious and unconscious biases and listening to the healthcare experiences of minoritized communities can help develop culturally and trauma-informed approaches that will ultimately deliver better outcomes [4, 6].

Community support should also be at the heart of how CVD prevention and care are delivered in LMIC settings, especially where specialist facilities are lacking and detection often comes late in the course of disease. In such contexts, the key to CVD reduction will be in the implementation of cost-effective programmes at a community primary care level [2]. However, the reality remains that a high number of national healthcare systems still require significant reorientations to effectively address CVD within universal health coverage packages [2].

Addressing health inequalities in CVD remains an urgent priority. Appropriately coproducing and targeting a range of public health interventions, as well as research programmes, towards improving health outcomes among those who are most disadvantaged will have substantial health and societal benefits.

Funding

World Healthy Life Week is funded in partnership by the Healthy Heart Trust and the Fellowship of Postgraduate Medicine.

Conflict of interest statement: None declared.

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