Racism, Abuse Linked to Higher Heart Failure Risk in Black Women

Black women face disproportionately high rates of heart failure and worse outcomes after diagnosis compared with White women, but the factors contributing to this disparity remain incompletely understood.¹ A new cohort study published in JAMA Network Open suggests that psychosocial stress, specifically experiences of interpersonal racism and childhood or adolescent sexual abuse, may be an underrecognized contributor.

“In this study, we evaluated the prospective associations between different domains of psychosocial stress that disproportionately affect Black women and incident heart failure in a large sample of Black women that included heterogeneity across geographic location, [socioeconomic status], educational level, and cardiovascular risk profiles,” the study researchers wrote. “Experiences of discrimination in employment, housing, or interactions with the police and a history of adolescent sexual abuse were both associated with increased heart failure risk after accounting for demographic and clinical risk factors.”

The investigators from Boston University analyzed data from 48,320 participants in the Black Women’s Health Study (BWHS), a large US cohort composed exclusively of Black women. Participants resided across all US geographic regions and were followed for a median of 24 years, from baseline racism assessments in 1997 through 2023. During follow-up, 1343 incident heart failure events occurred.

Discrimination Across Multiple Domains Raises Risk

Investigators assessed 2 dimensions of perceived interpersonal racism: a daily racism score capturing everyday interactions and self-reported discrimination in employment, housing, and encounters with police. More than half of participants (58%) reported discrimination in employment, 36% in housing, and 23% in interactions with police; 11% reported experiencing discrimination in all 3 domains.

After adjustment for demographic and clinical risk factors, discrimination in each domain was associated with higher heart failure risk, and risk increased with cumulative exposure. Women who reported discrimination in all 3 domains had a 27% higher risk of heart failure (HR, 1.27; 95% CI, 1.06-1.52) compared with those reporting none.

The daily racism score was also associated with heart failure risk in age-adjusted analyses (HR, 1.23 for highest vs lowest quartile), but the association was attenuated and no longer statistically significant after adjustment for clinical risk factors. BMI accounted for much of the attenuation.

Adolescent Abuse History Tied to Elevated Risk

Among the 31,420 participants who completed a 2005 questionnaire on childhood and adolescent abuse, a history of frequent (4 or more times) sexual assault during adolescence remained significantly associated with incident heart failure after multivariable adjustment (HR, 1.44; 95% CI, 1.04-2.00). The association for frequent childhood sexual assault was attenuated after adjustment (HR, 1.24; 95% CI, 0.92-1.65) and did not reach statistical significance.

Additionally, mediation analyses estimated that BMI accounted for approximately 19.6% to 35.9% of the associations between childhood or adolescent sexual assault and heart failure risk. The authors noted that this finding is consistent with prior BWHS research linking perceived racism with obesity.

The study authors also pointed to potential biological and behavioral pathways through which chronic stress could affect cardiovascular health, including hypothalamic-pituitary-adrenal axis activation and stress-related eating behaviors. These mechanisms, however, were not directly established by the present study.

The findings build on earlier BWHS research examining interpersonal racism and cardiovascular disease. A 2024 analysis published in Circulation found that discrimination involving employment, housing, and police interactions was associated with higher incident coronary heart disease risk among Black women, while everyday racism was not significantly associated with risk after multivariable adjustment.²

The study has several limitations. Heart failure was self-reported, although a subsample review found 78% concordance with adjudicated criteria.¹ The observational design also means that the findings demonstrate associations rather than causation, and residual confounding cannot be excluded.

In addition, measures of discrimination and childhood or adolescent sexual assault were based on participant self-report, potentially introducing recall or reporting bias. The long follow-up period also means that exposures and risk factors may have changed over time.

Managed Care Implications

For managed care organizations and health systems serving Black women, the findings suggest that traditional cardiovascular risk-factor assessment may not capture the full range of psychosocial factors associated with heart failure risk. Discrimination and histories of childhood or adolescent sexual assault could potentially serve as identifiable risk markers, although the study does not establish that screening for these exposures or intervening on them reduces heart failure incidence.

The findings may nevertheless support consideration of more comprehensive approaches to cardiovascular prevention that recognize social and psychosocial stressors alongside established risk factors.

“Our findings underscore that different aspects of psychosocial stress disproportionately experienced by Black women may portend elevated heart failure risk independent of sociodemographic risk factors, identifying additional risk factors that may underlie the disparity in heart failure risk among Black women,” the researchers wrote. “Further studies are needed to understand the biological pathways underlying this risk and how it may vary by heart failure phenotype.”

References

1. Davis DN, Aghi A, Gajjar P, et al. Psychosocial stressors and heart failure risk among Black women in the US. JAMA Netw Open. 2026;9(8):e2629320. doi:10.1001/jamanetworkopen.2026.29320
2. Sheehy S, Brock M, Palmer JR, et al. Perceived interpersonal racism in relation to incident coronary heart disease among Black women. Circulation. 2024;149(7):521-528. doi:10.1161/CIRCULATIONAHA.123.066471