Racial, Ethnic Disparities May Impact Age Differences at First Heart Failure Hospitalization

Black patients are more likely to be hospitalized for heart failure (HF) nearly 14 years earlier than White patients, according to a new study published in the Journal of the American College of Cardiology (JACC).¹

While the major clinical risk factors for HF are well known, the prevalence of these factors may vary depending on social determinants of health (SDOH). SDOH is defined as the conditions of an individual’s environment related to where a person was born, where they live, work, play, and worship, and their age, and is often grouped into 5 categories: economic stability, access to quality education and health care, neighborhood, and social community. In a systematic review from the Journal of the American Heart Association, economic instability, like poverty and unemployment, was associated with the inability to afford resources necessary for managing HF, like healthy foods, stable housing, and working utilities. Additionally, they associated poverty with increased toxic stress and adverse health effects like high blood pressure and inflammation.²

“Clinical risk factors likely also reflect upstream social determinants such as unequal access to preventive care, chronic stress, and structural barriers to health for minoritized groups,” the authors wrote in the JACC study.

The study used patient data from the American Heart Association’s (AHA) Get With The Guidelines-Heart Failure (GWTG-HF) registry—a voluntary in-hospital program aimed at improving care and promoting consistent adherence to the latest treatment guidelines—providing detailed information about each HF hospitalization. The analysis included patients admitted with their first HF hospitalization from January 2016 to December 2019. The first HF hospitalization was defined as patients hospitalized with no prior history or diagnosis of HF. The final study population consisted of 42,252 patients, of whom 968 (2%) identified as non-Hispanic (NH) Asian, 10,001 (24%) as NH Black, 3048 (7%) as Hispanic, and 28,235 (67%) as NH White. Other race and ethnic groups, such as Native American, Alaska Native, Native Hawaiian, or Pacific Islander, were not included due to the relatively small sample size. Furthermore, there were 2481 individuals with unidentified race or ethnicity data.

Assessed risk factors of first HF hospitalization were not limited to sex, insurance status, body mass index, systolic blood pressure, smoking status, and history of diabetes and ischemic cardiovascular disease. Area-based social risk factors were based on the American College of Cardiology and AHA SDOH definitions and measured at the year of admission. The factors were linked to patients’ residential zip codes to assess residents' socioeconomic status and health care resources in their county.

Age of First HF Hospitalization

Black patients had the youngest average admission age of 60.1 ± 14.7 years, followed by Hispanic patients at 65.4 ± 16.1 years. The average age of admission for Asian and White patients was relatively similar at 70.6 years ± 15.5 and 73.6 years ± 14.3 years, respectively. Social risk factors were associated with the largest observed difference in first HF hospitalization when comparing patient race and ethnicity. A difference in insurance status accounted for 47.8% and 59.8% of the difference in age at first hospitalization between Black and White patients and Hispanic and White patients, respectively. However, it was associated with 93.3% of the difference between White and Asian patients.

More specifically, the difference in age between Black and White patients can also be explained by a composite measure that includes unemployment rate, uninsured status, and public insurance enrollment (eg, Medicare, Medicaid, Veterans Health Administration, or Children’s Health Insurance Program), averaging a 3-year age difference at first HF hospitalization. Clinical risk factors, like smoking, were associated with a 1.2-year age difference when comparing Black and White patients.

“The findings highlight social factors that may play a meaningful role in shaping the risk of premature HF hospitalization,” the study authors wrote. “Differences in health insurance coverage likely influence access to preventive care, timely diagnosis, and medication adherence, contributing to earlier HF hospitalization among populations with higher rates of Medicaid coverage or uninsurance.”

The researchers noted that race and ethnicity are social constructs that are heavily intertwined with social determinants of health, with structural racism supporting many of the observed differences in social risk factors. A reflection of this system is apparent in the overrepresentation of Black and Hispanic individuals who live in areas with high unemployment and underinsurance.¹

Study Limitations and Conclusion

The study has several limitations. First, the definition of the first HF hospitalization may not reflect true disease onset, leading to potential misclassification, particularly among patients with fragmented care. Additionally, social and clinical risk factors were measured only once, lacked individual-level socioeconomic details (eg, income, education), and were linked at the county level, limiting precision. Finally, unmeasured or omitted factors may account for unexplained differences in age at first HF hospitalization across racial and ethnic groups.

“These persistent residual disparities suggest that unmeasured structural and systemic factors, including inequities in health care access, quality of care, and the cumulative effects of discrimination, may also contribute to the earlier hospitalization of HF in minoritized populations,” the study authors wrote. “Which requires broader evaluation and evaluation of policy-level changes to effectively address the disproportionate burden of HF, particularly premature HF, in vulnerable populations to advance health equity.”

References

1. Huang X, Hughes Z, Fonarow GC, et al. Racial and ethnic differences in patient age at first hospitalization for heart failure. J AM Coll Cardiol. 2025; 86(10). doi:10.1016/j.jacc.2025.06.046

2. Enard KR, Coleman AM, Yakuba RA, Butcher BC, Tao D, Hauptman PJ. Influence of social determinants of health on heart failure outcomes: a systematic review. J Am Heart Assoc. 2023; 12(3). doi:10.1161/JAHA.122.026590