Black Race and Male Gender Associated With Worse HF Risks, Rates

This new investigation, a subanalysis of participant data from the Atherosclerosis Risk in Communities study, examined race- and gender-based differences of heart failure (HF) risk at an older age.

For individuals aged 74 and older, new prospective, epidemiologic, cohort study findings among individuals without a history of heart failure (HF) show marked differences in left ventricular (LV) systolic function, LV concentric remodeling, and risk of HF with reduced ejection fraction (HFrEF) by race and gender.

Because of these risk variances, the investigators concluded that additional studies are needed on the factors that contribute to these race- and gender-based differences, both in cardiac performance and HF risk among older patient populations, report investigators in the Journal of the American College of Cardiology.

“HF incidence and prevalence are highest in late life, with ≥ 80% of HF hospitalizations occurring in persons ≥ 65 years. Most community-based persons in this age range have HF risk factors or asymptomatic cardiac dysfunction and are at elevated risk for developing symptomatic HF,” the authors wrote. “However, despite important influences in early adulthood and midlife, race- and gender-based differences in HF risk factors, cardiac structure and function, and incident HF in late life remain understudied.”

Examining participant data (N = 5149; mean [SD] age, 75 [5] years; 59% women; 20% Black) from their fifth visit (between 2011 and 2013) during the Atherosclerosis Risk in Communities (ARIC) study, correlations were seen between the following:

  • Male gender and Black race with lower mean LV ejection fraction (LVEF)
  • Black race with greater LV wall thickness and concentricity, after adjusting for cardiovascular (CV) comorbidities
  • Male gender and Black race with higher risks of overall HF and HFrEF, after adjusting for CV comorbidities
  • Black race and male gender with higher incidence of overall HF and HFrEF

Echocardiography was performed at the fifth study visit, while gender and race information were self-reported at the first study visit. The median (interquartile range) follow-up was 5.5 (5.0-6.0) years, until incident HF or death. For this study, HFrEF was defined by an LVEF of less than 50% and HF with preserved ejection fraction (HFpEF) by an LVEF of 50% or above. The most common comorbidity was hypertension in 81%.

Looking at the specifics of each, the mean (SE) LVEF in Black men was 63.1% (0.3%) vs 64.5% (0.1%) in White men, with more Black men also having an abnormal LVEF, “indicated by values worse than the ARIC-based reference ranges,” the authors wrote. Women of both races had higher mean (SE) LVEF, at 66.0% (0.2%) in Black women and 66.9% (0.1%) in White women.

Close to 14% fewer Black men in this analysis had normal LV geometry vs White men (42% vs 49%), and 30% more had LV concentric remodeling vs White men (43% vs 30%). The respective mean (SE) LV end-diastolic diameters were 4.46 (0.03) cm and 4.63 (0.01) cm, showing enhanced LV wall thickness.

For risk of HF overall, the event rate was per 1000 person-years and translated into an elevated risk. Among Black men, the age-adjusted rate was 19.7 (95% CI, 12.6-26.8) vs 13.6 (95% CI, 11.2-16.0) for White men, for an overall 45% greater risk (HR, 1.45; 95% CI, 0.97-2.16). Adjusting for age and risk factors (eg, age, hypertension, body mass index, diabetes history of coronary heart disease, atrial fibrillation, education level) showed a 65% greater risk (HR, 1.65; 95% CI, 1.07-2.53).

Focusing on HFrEF, the gap in risk widened even more, with an event rate of 13.3 (95% CI, 7.4-19.1) in Black men vs 6.3 (95% CI, 4.6-7.9) in White men, representing a 112% greater risk of this HF subtype when adjusting for age (HR, 2.12; 95% CI, 1.27-3.54) and a 155% greater risk when adjusting for age and the aforementioned risk factors (HR, 2.55; 95% CI, 1.46-4.44).

When looking at the rates and risk among women of both races vs men, the numbers were universally lower:

  • Overall event rates for incident HF were 8.6 (95% CI, 5.4-11.8) in Black women and 9.8 (95% CI, 8.1-11.6) in White women
  • Black men had a 120% greater risk and White men a 34% greater risk of incident HF vs women of their respective races overall, after adjusting for age
  • Black men had a 136% greater risk and White men a 16% greater risk of incident HF vs women of their respective races overall, after adjusting for age and risk factors
  • Event rates for HFrEF were 3.8 (95% CI, 1.6-5.9) in Black women and 3.1 (95% CI, 2.1-4.1) in White women
  • Black men had a 241% greater risk and White men a 94% greater risk of HFrEF vs women of their respective races, after adjusting for age
  • Black men had a 270% greater risk and White men a 55% greater risk of HFrEF vs women of their respective races overall, after adjusting for age and risk factors

Race- and gender-based differences were not evident among persons with HFpEF.

Because only 62% of study participants who were alive for the fifth ARIC study visit chose to attend, a majority of Black participants were from 1 study center, and the LVEF cutoff for HFrEF could not be adjusted down to 40%—because doing so would see a large drop in event rates—these study findings may not be generalizable.

“Further studies are necessary to better understand the factors contributing to these gender and race-based differences in cardiac performance and HF risk in late life,” the authors concluded.

Reference

Chandra A, Skali H, Claggett B, et al. Race- and gender-based differences in cardiac structure and function and risk of heart failure. J Am Coll Cardiol. 2022;79(4):355-368. doi:10.1016/j.jacc.2021.11.024