Hospital survival differs among Hispanic and non-Hispanic heart failure patients
Gerald Hurowitz, M.D.·Published 15 March 2012·7 min read
Key points
The study, published in the American Heart Association journal, Circulation: Heart Failure, is the first in which researchers compare the care and outcomes of Hispanic to non-Hispanic heart failure patients admitted to U.S. hospitals with either preserved (normal) or reduced heart function.
The finding that hospitals improved their adherence to quality of care guidelines for all heart failure patients, regardless of ethnic background, is encouraging, according to Vivo.
Hispanics are uniformly affected by excessive rates of diabetes, overweight and obesity, atherogenic dyslipidemia, metabolic syndrome, and poorly controlled hypertension.
"Hispanics have multiple risk factors for heart failure and many face barriers to receiving health care," said Rey P.
The odds of surviving their hospital stay for heart failure differ between Hispanic and non-Hispanic white patients according to their level of heart function, even when they received equal care in hospitals participating in the American Heart Association's Get With The Guidelines® - Heart Failure quality improvement program, researchers said.
The study, published in the American Heart Association journal, Circulation: Heart Failure, is the first in which researchers compare the care and outcomes of Hispanic to non-Hispanic heart failure patients admitted to U.S. hospitals with either preserved (normal) or reduced heart function.
"Hispanics have multiple risk factors for heart failure and many face barriers to receiving health care," said Rey P. Vivo, M.D., lead author of the study and a fellow in the Division of Cardiology at the University of Texas Medical Branch in Galveston and the Methodist DeBakey Heart and Vascular Center in Houston, Texas. "Hispanics make up the largest and fastest growing ethnic minority in the United States. Yet, we know very little about the quality and results of care for Hispanic heart failure patients."
Researchers reviewed data from 247 U.S. hospitals in the Get With The Guidelines-Heart Failure program in 2005-2010. They divided Hispanic and non-Hispanic white patients into groups based on preserved or reduced ejection fraction.
Ejection fraction measures a heart's contracting ability by how much blood the left ventricle pumps out with each heart beat. Heart failure patients with reduced heart function have lower than normal ejection fraction measures.
The researchers found:
Among patients with preserved (normal) heart function, Hispanic patients were 50 percent less likely than non-Hispanic whites to die during their hospital stays. There were no differences in hospital survival between Hispanic and non-Hispanic heart failure patients with reduced heart function. There were no major differences in quality of care among any Hispanic and non-Hispanic whites, regardless of heart function. The quality of care at Get With The Guidelines-Heart Failure hospitals improved consistently during the five years of the study.
In general, Hispanic American adults are 20% less likely to have coronary heart disease than non-Hispanic white adults. They are also less likely to die from heart disease than non-Hispanic white adults.
In 2010, Hispanics were 20% less likely to have heart disease, compared to non-Hispanic whites. In 2008, Hispanic men and women were 40% less likely to die from heart disease, compared to non-Hispanic whites.
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Source: CDC 2011. Summary Health Statistics for U.S. Adults: 2010. Table 2.
Written and revised by
Gerald Hurowitz, M.D.
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"One possible reason for the survival difference between heart failure patients with preserved heart function is that Hispanics tend to be younger and may not be as sick as hospitalized white heart failure patients," Vivo said. "That could be because Hispanics are more likely to have inadequate or no health insurance. So, they are more likely to go to the hospital for their care, versus seeking care in doctors' offices or outpatient clinics."
Heart Failure in Hispanics By midcentury, minorities are projected to become the majority in the U.S. Playing a central role in this demographic shift are Hispanic Americans who lead all ethnic groups in the U.S. in number and rate of population growth.
Presently, 45.5 million Hispanics live in the U.S., comprising 15% of the total population. Spurred by higher birth rates and immigration, this number is expected to nearly triple to over 130 million by 2050, when it is projected that 1 of 3 U.S. residents will be Hispanic. As the public health burden of heart failure (HF) continues to increase in the general population with its health care-related cost amounting to nearly $30 billion, its consequences are expected to be magnified among Hispanics for 3 key reasons. Foremost, the remarkable growth in the Hispanic population is expected to present a challenge to the health care system. Second, Hispanics have a disproportionate cardiometabolic risk burden, making them an important population to elucidate the association between novel metabolic risk factors and HF outcomes. Finally, they are significantly and unfavorably affected by health care disparities shaped by multiple socioeconomic, contextual, and cultural factors.
Between 2000 and 2006, the Hispanic population grew almost 4 times faster (24.3%) than the total U.S. population (6.1%). Approximately 1 of every 2 persons added to the national population between 2005 and 2006 was Hispanic, thereby accounting for nearly one-half of the population growth during that period. The majority of Hispanics in the U.S. are of Mexican origin (64%); Puerto Ricans (9%), Cubans (3.4%), and Dominicans (2.8%) constitute other major national groups. Although the largest number of Hispanics resides in California, Texas, Florida, New York, and Illinois, the highest Hispanic growth rate has been reported in the Southeast, particularly in the states of Arkansas, Georgia, South Carolina, Tennessee, and North Carolina. Mexicans comprise nearly one-third of the population in Texas and California; approximately one-half of the nation's Dominicans live in New York City, and about one-half of the nation's Cubans reside in MiamiDade County, Florida. More than 90% of Hispanics reside in metropolitan regions - a trend strongly driven by migration from rural farm jobs to urban city occupations that began in the 1950s.
American Heart Association 2008 statistics revealed that the prevalence of HF was lowest in the Mexican-American subgroup, followed by non-Hispanic whites and African Americans. The annual prevalence rates for men were 2.1% in Mexican Americans, 2.8% in non-Hispanic whites, and 2.7% in African Americans. For women in the same populations, the prevalence rates were 1.9%, 2.1%, and 3.3%, respectively.
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Rey P. Vivo, MD, Selim R. Krim, MD, Cihan Cevik, MD, Ronald M. Witteles, MD
The finding that hospitals improved their adherence to quality of care guidelines for all heart failure patients, regardless of ethnic background, is encouraging, according to Vivo.
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"The study suggests that participation in quality of care initiatives, such as Get With The Guidelines, is a positive step toward reduction in healthcare disparities, in terms of delivering quality of care to all heart failure patients," he said.
Risk Factors for Heart Failure
Hispanics are uniformly affected by excessive rates of diabetes, overweight and obesity, atherogenic dyslipidemia, metabolic syndrome, and poorly controlled hypertension. The conglomeration of these conditions, including related pathophysiologic components that are emerging as novel risk factors for Heart Failure, is expected to amplify the risk of this ethnic group for Heart Failure.
Diabetes. Hispanics are nearly twice as likely to have diabetes as age-matched non-Hispanic whites. Moreover, the increase in diabetes prevalence from 2005 to 2050 is expected to be highest among Hispanics. The high prevalence of diabetes in this ethnic population has been attributed to higher rates of obesity, highly atherogenic diet consumption, and genetic susceptibility. Diabetes-related microvascular complications and mortality are higher in Hispanics than in non-Hispanic whites. In addition, diabetic Mexican Americans less frequently self-monitor their blood glucose and have poorer glycemic control than non-Hispanic whites.
Although data have shown that low socioeconomic and educational status, poor medical care access, and inability to speak English do not predict worse glycemic control in Hispanics, a recent study reported that modifiable selfmanagement behaviors, particularly higher diabetes-specific emotional distress, contribute to uncontrolled hyperglycemia in this population.
Poorly controlled diabetes predicts a higher risk of Heart Failure. The UKPDS (United Kingdom Prospective Diabetes Study) documented that every 1% incremental rise in glycated hemoglobin increased the risk for nonfatal Heart Failure by 16%. There is growing recognition of a "diabetic cardiomyopathy" that accounts for the increased risk of developing Heart Failure among diabetics in the absence of coronary artery disease (CAD), hypertension, or other known structural heart disease.
Data from MESA indicating ethnic differences in diabetesassociated LV abnormalities, wherein increased LV mass and wall thickness were completely attributable to subclinical atherosclerosis and hypertension in non-Hispanic whites but not in Hispanics, suggest a greater contribution from diabetes in the latter group.
Obesity. More Mexican-American men are overweight than their non-Hispanic white and African-American counterparts. They also have a higher proportion of abdominal fat than women. Among women, a higher percentage of Mexican Americans are overweight and obese than non-Hispanic whites. Hispanic adults (47.6%) are less likely than African Americans (51.3%) and non-Hispanic whites (66.1%) to engage in leisure-time physical activity.
In future studies, researchers should focus on what happens to heart failure patients from diverse ethnic groups after they leave the hospital, such as looking at readmission rates for six months or one year, Vivo said.
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Co-authors are Selim R. Krim, M.D.; Nassim R. Krim, M.D.; Xin Zhao, M.S.; Adrian F. Hernandez, M.D., M.H.S.; Eric D. Peterson, M.D., M.P.H.; Ileana L. Piña, M.D., M.P.H.; Deepak L. Bhatt, M.D., M.P.H.; Lee H. Schwamm, M.D.; and Gregg C. Fonarow, M.D.
Author disclosures are on the manuscript. The Get With The Guidelines-Heart Failure program is provided by the American Heart Association and is currently supported in part by Medtronic and Ortho-McNeil and has been funded in the past through support from GlaxoSmithKline.
Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association's policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content.
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Cathy Lewis cathy.lewis@heart.org 214-706-1324 American Heart Association
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