Racial Disparities in Women’s Heart Health: A Prevention-focused Approach

All right. Hi, everyone. How are you doing today? Thank you for joining today’s webinar. Racial Disparities in Women’s Heart Health: A Prevention Focused Approach. My name is Tricia Winchester. I’m a clinical educator for the Quest Cardiometabolic Center of Excellence at Cleveland Heart Lab. I’ll be introducing our speaker and moderating today’s question and answer session. You are joined in listen only mode. With February being Black History Month, American Heart month, We’re delighted to combine aspects of both topics together to provide education and awareness, taking a step and ensuring a healthier tomorrow for everyone. To that note, Quest Diagnostics launched an initiative called Quest for Health Equity in August of 2020. The organization’s mission is to close the health disparity gap among the underserved,put an emphasis on mitigating testing disparities and addressing the root causes of health inequities. We are proud to invite Dr. Rachel Bond to provide important awareness and education of the leading cause of death in the United States: heart disease. The sooner an at risk individual is identified, the sooner targeted preventive strategies can be initiated. Before we begin, first, a few housekeeping items. We are recording today’s program, and we’ll be posting it on our education center as a future On-Demand occasional offering so you can review this valuable information in the future and share it with colleagues who couldn’t join us for today’s live program. One Pace Credit will be available for this presentation. The link to the evaluation should appear after this presentation as well as in a follow up email. Please ask your questions in the Zoom chat on the the bar below and they’ll be answered during the Q&A portion of the program. And now I have the pleasure to introduce our wonderful speaker, Dr. Rachel Bond. She is a board certified attending cardiologist who has devoted her career to the treatment of heart disease through early early detection, education and prevention. She is assistant director of women’s Heart Health at Dignity, Health and Arizona. Dr. Bond is the co-chair of the woman Cardiology committee, as well as the chair of Diversity and Inclusion Committee for the Arizona Chapter of the ACC, American College of Cardiology. She most recently has been appointed to serve on the Women in Cardiology section Leadership Council for the National chapter of the ACC. She holds a faculty position as an assistant professor of internal medicine at Creighton University School of Medicine. Dr. Bond is the author of several review papers referencing sex and gender differences and cardiovascular conditions that predominantly affect women, along with opinion pieces aimed at addressing health equity, reducing health disparities and promoting the professional development of women and minorities in the health science profession. She has a passion for advocacy of education and mentorship and has advised as an expert source through news and media outlets. Her clinical interests include heart disease prevention, pregnancy related heart conditions and cardio oncology and lipid disorders. As you can see, our mission is greatly, greatly aligned and we are thrilled to have her speak here today On the racial disparities in women’s heart health. Dr. Bond, please take it away. Thank you so much, Tricia, for that amazing introduction. And thank you all for joining today. As Tricia said, I will be discussing the racial disparities in women’s heart health, and it’s really going to be predominantly focusing on prevention and how we can better improve the cardiovascular disease outcomes that we’re seeing in the most vulnerable patient populations. So with that, I have no disclosures in terms of the outline of our talk today. We’re going to start by really reviewing the current state of cardiovascular disease and the impact social determinants of health play on it. We’re then going to expand on the gaps that we may see when it comes to actually risk stratifying these patients. And then lastly, and probably most importantly, we’re going to discuss clinical tools that can help us in terms of treatment decision pathways. So to begin, let’s focus in on those social determinants of health and how they actually play a role when it comes to the current state of cardiovascular disease. And I always like to start on all of my lectures really by painting a picture, a picture that really does demonstrate that heart disease remains to be an equal opportunity killer. So what does this graph actually demonstrates is that before the 1980s or really the mid 1980s, we were seeing that men in blue, women in red were dying at much higher rates from cardiovascular disease. And it really wasn’t until the mid 1980s where there began to be a steady decline in the number of deaths from heart disease in men. But what did we also begin to see was a steady increase in the number of deaths in women. Why was that? And that’s always important to ask. Well, we know that in the mid 1980s we had the advent of medications such as statins, for example. We also had angioplasty, which unfortunately all of those measures were disproportionately provided to men and not as aggressively provided to women. So it made logical sense that there would be a decline in men, but an increase in women. And it really wasn’t until the year 2000 when somebody really wanted to take note of this and said, why are there these disparities? Do we need to do more research that’s focused on women? And the FDA and other organizations such as the NIH said, yes, we need to make sure we enroll more women into trials. But also, what happened in the early 2000s was the American Heart Association created the go red for Women campaign, which wanted to increase awareness of heart disease as the greatest threat in women. And beyond that, the American Heart Association joined forces with the American College of Cardiology to come up with really amazing guidelines that were specific to gender, specifically with women. And now what are we seeing? We’re seeing that we’re having a notable decline in both men and women. But actually, what’s more interesting for me is that the later years are actually seeing that there’s a trend upwards. But is this trend upwards or in the wrong direction across the board in terms of age and even gender? And the answer to that is no. When we think about where we’ve come over the past four decades, we know that heart disease has steadily declined. Even when we think about deaths from heart disease, particularly in those above the age of 65, where we’re seeing the actual increase or more of a slow improvement happens to be in the younger population, 35 to 54, especially if they’re women, especially if they’re black women. And overall, the American Heart Association has looked at statistics when it comes to actually race and ethnicity. And we know that African African-Americans overall have the lowest prevalence of what we would call ideal components of health. So what does that include? A blood pressure that’s under control, someone that doesn’t smoke, somebody who eats a healthy diet. And actually, because of that, we know that they have the highest prevalence of total cardiovascular disease among all racial and ethnic groups, about 60% in men and also about 60% in women. And because of that as well, we see that across race and ethnic groups, they have the highest rate of mortality. Now, one thing that’s important to note is that nothing captures the nature of health inequities as clearly as a persistent life expectancy gap between white and black Americans. And what we can see very nicely here in this graph is that when it comes to life expectancy, white male versus white females, we see that a white female lives, on average about 81 years versus a black female, 78 years, a white male lives on average about 76 years, versus a black male who is actually about 71 years. Recent data actually just came out today that shows that since the pandemic that actually has further decline, where within six months of 2020 that there has been a decline or even three years in black men and almost two and a half years in black women. So further disparities that we’re seeing. But again, this life expectancy really highlights these disparities. And why is that? We know that people, when they have a lower life expectancy, the leading cause usually is that death from cardiovascular disease, particularly heart disease. And we know that that does disadvantage the black community. Beyond that, though, when we think about areas, particularly of mortality, white Americans on the left graph, white black Americans on the on the right graph, we see that the gap in the differential between mortality rates are much wider in the black community were again at the very top. All forms of cardiovascular disease tends to be the leading overall cause. Now what is the most predominant thing when when you think about cardiovascular disease that’s leading the number of deaths from cardiovascular disease, it actually happens to do with hypertension. And we know that the black community in general has much higher rates of hypertension. In fact, if we’re focusing on black women, we know that a black female above the age of 20, 50% of the time will have some form of cardiovascular disease, which the most common being related to high blood pressure. And that then makes us talk about the fact that black women are really, in theory, the highest risk population when we’re dealing with cardiovascular complications. And why is that? That’s really what the bulk of this talk is going to be focusing in on. So let’s go through the why. So when we think about why, even when people are presenting to the hospital, we know that women in general, when they present, they tend to have higher rates of mortality, specifically when presenting with signs or symptoms of heart attacks such as myocardial infarction. Beyond that, though, when we actually look into the age and specifically the gender and specifically the race, again, we’re seeing that it’s the 35 to 54 years female and women that identify as black that have the highest rates of mortality in the hospital. A lot of this has to do with the fact that there are less likely to receive guideline treatment such as a baby aspirin or even a cholesterol lowering medication like a statin. Beyond that, though, they’re less likely to undergo invasive strategies used to open up that blocked artery if there is a myocardial infarction such as a coronary angiogram. But when done even happens after discharge, from a discharge perspective, they’re less likely to be discharged on those guideline directed medical therapy and even referred to cardiac rehab. Cardiac rehab, we know, is something that has been instrumental in lowering our overall risk and in terms of complications from long term cardiovascular disease. But women tend to not only be less referred, but when they are referred they’re less likely to complete it. And that’s something that we’re looking at into how can we better equip cardiac rehab for a woman, maybe a working mom, for example, who may have the opportunity, might not have the opportunity to go during the work hours to cardiac rehab. Beyond that, though, from cardiovascular disparities, we know it’s beyond even coronary artery disease. We see it in heart failure in arrhythmias and peripheral arterial disease and valvular disease as well, where women are less aggressively treated versus men. And one reason this may be is because awareness is lacking. With all the strides we’ve made with the Go Red for Women campaign with the American Heart Association, One thing that was really notable for me was that they did a survey comparing the awareness of heart disease in women in 2019 versus that in 2009 and in 2009, 65% of the population of women actually knew that heart disease was their greatest threat. That has since declined to 44% as of 2019. And when we’re looking at the populations that have the greatest lack of awareness, it’s again, young women, 25 to 34 who identify as Hispanic or black. So those are the areas we need to target. Beyond that, though, we know that a lot of disparities in poor outcomes have to do with the fact that women present with atypical symptoms. So when you think about a classic heart attack, you always think about someone clutching the center of their chest as though an elephant is sitting on their chest. And although that does occur in both men and women, we know about a third of the time women may not even have chest pain. They may have more shortness of breath. They may have back pain. They may even feel something like fatigue that’s persistent, perseverating. But could be a red flag that there’s something going on. We also know that other causes of these poor outcomes, particularly in women, is the fact that research is notably underrepresented when it comes to women. There’s only about still, despite the efforts of all of the strides we’ve made, there’s still only about a 20 to 30% female inclusion for a lot of our major research trials. Now, we talk a lot about the ethnic racial minorities. And as I touched upon, we know that black women in general are the greatest risk. But beyond that, we have to factor in Latin X, Afro-Caribbean, South Asian. Those are higher risk groups as well. And even beyond that, indigenous groups, particularly for myself, I’m in Arizona where we have a large proportion of the Native American community that has very high rates of cardiovascular disease. Beyond race, though, think about a geographical area. And we know that women that live in rural or more remote residences actually experience higher rates of cardiovascular disease. Income factors in as well, and we’re going to delve into the social determinants such as socioeconomic status. But one caveat to income is that the maternal mortality crisis, which is honestly an epidemic in the United States, as we’re the only industrialized country that has the highest rates of death for mothers during pregnancy and up to one year postpartum with heart disease being the leading cause is irrespective of your socio economic status. We are seeing that particularly in black women, they have the highest rates 3 to 4 times more likely to die during their pregnancy and postpartum period solely because they are a black female in America and it has nothing to do with income. Beyond that, though, we know that there are sex specific risk factors that are more unique to women. So why is it that the maternal mortality crisis is actually heart disease is leading the cause? Cause a lot of complications that could occur during pregnancy can place us at a higher risk in the future for heart disease. So those include gestational diabetes or hypertension, pre-eclampsia, where we have an elevation, blood pressure and we spill a lot of protein in our urine. Even having a premature labor places a female at a heightened risk for heart disease in the future and it’s the very near future, the next 5 to 10 years. Beyond that, though, we know anxiety, depression and chronic stress are also unique risk factors to women. Why? Because they’re more prevalent in women, but also they tend to lead to higher rates of poor outcomes when it comes to heart disease if women experience them. Beyond that as well, autoimmune or inflammatory conditions which disproportionately affect women, especially women of color like lupus and rheumatoid arthritis, can also lead to premature heart disease. And even further beyond that, we have to think about all the strides we’ve made when it comes to breast cancer treatment to the point that it’s over 95% survival, but with a 95% survival, with the chemotherapy and the radiation therapy, that can furthermore lead to some accelerated heart disease or premature heart disease. So close collaboration with the oncologists and the community for us as cardiologists is so important. And I put up there also hormone therapy, which can be controversial in of itself. But we know that when it comes to the use of hormone therapy, it’s never suggested to start it to reduce one’s risk of heart disease. But we as cardiologists can help primary care doctors to determine who would be safe to initiate it for more of the hot flashes and those vasomotor symptoms, because if you have a patient who a higher risk, you may want to actually hold off on using hormone therapy and think about other measures. Beyond that, fertility does play a role. Failed fertility treatment, multiple miscarriages, for example, is a risk factor in the future for women, for heart disease, early menopause, early menarche, meaning early menses is also a risk factor. And moving forward to the more traditional risk factors like the diabetes, the hypertension, the obesity, the physical inactivity, or the smoking. Those are what make heart disease 80% of the time preventable. But interestingly enough, when women have those conditions, they’re at a much more heightened risk for having complications such as a stroke or heart attack then their male counterparts. And when we think about the underlying disease itself, as I mentioned, yes, biology and genetics does play a role, but we also have to and we cannot ignore the environment, the exposures that we may experience play a larger role. And that’s why it’s really interesting when we think about the concepts of race. It’s really, in all honesty, a flawed idea, right? And we have an overreliance. When we do have an overreliance on race, we may undervalue the other things like the social determinants which I’ll be delving into, such as the socioeconomic status, the geography and most importantly, one thing I wanted to emphasize, most notably in the African-American female community is the stress and lifestyle. So there is something called superwoman phenomenon, which is the legacy of strength in the face of stress, that in that stress can be just the misogyny of being a woman or the racism of being a black female. And that stress may actually lead to the current health disparities that disproportionately affect and plague African-American women. The reason being is we know that chronic stress leads to that weathering and that premature heart disease in this patient population. So we have to acknowledge that. And it goes so much more beyond just race and genetics itself. So let’s talk about these social determinants. And the American Heart Association did release a scientific statement in 2015 actually, that that really gave a good summary of what this encompasses. And when we think about the social determinants, we know, again, socioeconomic position factors in. Race and ethnicity does too, But beyond that is the social support, the culture, language and if there are language barriers, right, why is that important? Because there may be issues when it comes to health literacy. Beyond that, access to care is such an important and impactful thing. And then, of course, the residential environment that you’ve grown up in. And that’s really what the social determinants of health are: where you were raised, where you were, where you work and where you live with your family. Beyond that, when we really look at the markers of socioeconomic position, we know that health, education and again, access to a valued personal environment, not just at work, but even within your community is important. Having a political voice in that infrastructure is important as well. And then we have to also think about, again, the environment. Is there physical insecurity? Are there heart high crime rates? There are high violence. From an environmental perspective, we talk a lot about food deserts, which are areas where you may not have access to the healthy foods that we as doctors are suggesting for our patient population. So we have to do a better job as clinicians in actually looking for and searching for these social determinants within our patient population and helping to come up with solutions and ways to potentially work around it. And again, why is this important? Because when we think about income and life expectancy, it’s really impactful. And this was actually looked at in a JAMA article in 2016, and I think the graph really highlights it very nicely where we know that overall women tend to outlive men just regardless of what their race or ethnicity may be. But when we look at women particularly that had a much lower life expectancy, they actually were more likely to have a lower income versus similarly, we saw in men they had a much lower life expectancy, they had a lower household income. So social determinants of health definitely factor into even our life expectancy. But beyond that, I talk a lot about access, and this was looked at specifically for Medicaid expansion. And this is something that I’m extremely passionate about, even when it comes to the maternal mortality crisis, because we know right now to date, Medicaid is really only covering up to six weeks postpartum. As I said before, those mortalities and those complications can occur up to one year postpartum with heart disease being the leading cause. So expanding Medicaid and access to health care is without a doubt going to help us get it improved. Number of poor outcomes that we’re seeing in this patient population. And this actually was shown, furthermore, with the Affordable Care Act that if we expand Medicaid coverage, we have an opportunity to, without a question, decrease the number of deaths from cardiovascular disease. Now, I talked a lot about these social determinants, and this is just a very nice graphic form of it. But really the take home of this section is, is that many of the biggest drivers of health are so far beyond the scope of health care alone. And we know that actually when you delve deep into it, 60% of what dictates our health has to do with our personal behaviors, environment and our social factors. The rest has to do with our health and also our genetics, of course. But the biggest thing at the core of this, particularly for these most vulnerable populations, such as black women, are the historical legacy of structural racism. And this is something that even the American Heart Association, about a month or two back highlighted in another scientific statement to really take a stand and say that the disparities that we’re seeing in the cardiovascular world are rooted in structural racism, and we have to acknowledge it and we have to change it. Now, why is that important? So this is another graph that I think really paints a lot of pictures here of what we think about the problem. The problem is, is that people are dying from heart disease, but we know disproportionately black women, young black women are dying from heart disease. And when we think about the causes of cardiovascular disease, I listed a few of them, all of the traditional ones, the cholesterol, the blood pressure, the obesity, the diabetes, the smoking use age also being a factor. We know the older we are, the higher our risk. Any female above the age of 55, any male above the age of 45. Of course, we have to highlight family history as well, but that’s something we can’t modify. But beyond that, those sex specific risk factors I talked about and those other risk factors that are more predominant women, I talked about. But imagine that. And then adding the social determinants of health to the mix, such as poor access to food, access to health care, and most notably the discrimination, the constant discrimination and possibly even mistrust. You can only imagine what that is doing to our most vulnerable patient populations, and it needs to be acknowledged and we need to do a better job in screening for it. So that leads us to the next part, which is, well, what is the role of screening when it comes to primary prevention, meaning capturing risks before disease actually starts? And I want to before I talk about the role, I want to actually delve into the gaps that we may see and why our use of our current risk assessments may not be ideal for all of these vulnerable patient populations. So let’s stop start by talking about the blood pressure and cholesterol guidelines. And when we think about the guidelines, we know that it’s actually a really clear path, right? People that have an LDL cholesterol above 190, if you’re a diabetic between the ages of 40 to 75, you would qualify without a doubt, to be starting on a lipid lowering medication, usually a statin, which is the mainstay. But then we have areas of kind of, you know, where it becomes murky, like our 20 to 39 year of age group or our 40 to 75 year of age group. And it’s in that population, those particularly that don’t meet criteria immediately for a statin because their LDL is not above 190 or they’re not diabetic where we need to use this risk calculator. So the risk calculator includes our age, sex, race, blood pressure, what our cholesterol makeup looks like if we’re diabetic, if we were ever a smoker or if we’re on medications or were we ever on a statin or on an aspirin. But most importantly, at risk stratify is us into a low risk group, high risk group, a borderline or intermediate risk group. And I start with the low and high because those are the groups that are easy for us to think about. The low risk group, we know if you’re low risk less than 5%, there’s likely no need for you to be on a lipid lowering medication. What we’re going to suggest is aggressive lifestyle changes, eating healthy, exercising at least 150 minutes per week or some form of mild or moderate cardio. But the high risk group, without a question, should be on a lipid lowering medication. Again, mainstay being a statin in addition to the lifestyle. But what about that borderline to intermediate risk group where again, we can have a conversation with our patients to say, well, your risk is borderline, your risk is intermediate, maybe we need more information for me as a clinician to better help us figure out what your actual risk score is and what’s important for me, I particularly as a cardiologist who’s a preventive cardiologist, is that we’re not just focusing in on the 10 year ASCVD risk, but we’re also focusing in on the lifetime risk, and that’s our 20 to 39 year old population because we can help them see if they don’t change their lifestyle in that young age, what their future in the next lifetime is going to look like. So it’s a really impactful way for us to at least get ahead of the curve and talk about lifestyle. But one thing that’s important is that our risk estimation tools, they have limitations without a question and that’s why I was really encouraged by the fact that risk enhancers were considered in the new lipid lowering and the prevention guideline guidelines from the American Heart Association, the American College of Cardiology. And why do they need these risk enhancers? Because the fact is, is that despite people qualifying for the use of statins, it is underutilized. So what is a group that qualifies, of course, secondary prevention, somebody who has known atherosclerotic cardiovascular disease. But from a primary prevention perspective, even those with the LDL above 190 or who are diabetic a third of the time or not being prescribed statins. And when you actually delve into it from gender, we actually see that women also remain less likely than men to receive statins because of that, their mean LDL is so much higher in women versus men. But beyond gender, what about race? African-Americans are also less likely to be treated with statin despite actually meeting criteria to start it. And this was actually looked at in another JAMA cardiology article in 2018 where they found that African-American kids were less likely to be prescribed the statin and also less likely to receive inappropriate statin dosing. So when we think about if someone’s high risk or has underlying ASCVD, we think about the initiation of a high intensity statin. And unfortunately in the African-American community they were less likely to be started on such. Beyond that, though, we know that because of this they’re less likely to reach the LDL goals that we think would be best. So if somebody has underlining atherosclerotic cardiovascular disease, that’s usually a threshold well below 70. But our target in our aim and the general primary prevention population really should be a threshold less than 100 and the African-American community were less likely to reach this. Now, when they surveyed African-Americans, they asked, what are your thoughts on safety? What are your thoughts on effectiveness? What are your thoughts on trusting your clinician? And yes, African-Americans compared to Caucasians, were less likely to feel that statins were safe, they were less likely to feel that they were effective and they were less likely to trust their clinician. But it is beyond this because I think it has a lot more to do with what we as clinicians are expressing and explaining to our patients. And also are we actually risk stratifying these patients accordingly? Because I think in of itself there are other factors we have to take into account, such as these risk enhancers that will help us to determine what the person’s actual risks may be. And part of these risk enhancers beyond, you know, if you fall in that borderline or intermediate risk and you have a family history of premature heart disease, that may be somebody who we would be more aggressive with and consider starting them on a statin, or if they have underlying kidney disease, metabolic syndrome, which I’ll be talking about in a little bit, or even those female specific risk factors I talked about, like pre-eclampsia, premature menopause, or even those inflammatory conditions I talked about like rheumatoid arthritis or lupus. But I like the fact that ethnicity is part of this discussion as well. And they emphasize South Asian ancestry, but we also have to emphasize, again, African Americans, too. And beyond that, I’m going to delve later on into kind of what other things that may be a part of these risk enhancers such as laboratory data. But one thing that I think that was so impactful for me when I compare the American guidelines to the European guidelines, was that in their risk enhancers or risk modifiers, you actually include social deprivation, which is again, the origin of many causes of CVD. They also included psychosocial stress such as, such as vital exhaustion that would put somebody at a heightened risk for future cardiovascular event. Is this something we in America need to consider? Without a doubt. But I really encouraged by the fact that at least in Europe, they have started that process in their most recent 2019 European Society of Cardiology guidelines. But what other clinical tools do we have? And that’s really where, you know, I want to end the bulk of this talk that will help us make treatment decisions. And when we think particularly of cardiovascular disease risk tests, we know that metabolic syndrome is something that’s important for us to identify. So the way that we diagnose metabolic syndrome is by having 3 of the 5 following possibilities. Either you have a patient who’s obese, who has elevated blood pressure, who has an abnormal triglyceride or elevated triglyceride level or a low HDL level or even beyond that has a very large waist circumference. If they meet three of those five criteria, by definition, they have metabolic syndrome. And in these particular patients, it may be reasonable for one to consider doing a metabolic risk panel where we’re able to actually look at their insulin resistance like an insulin resistance assay that can help predict the possibility of a future cardiovascular issue. And although current evidence shows that such insulin assays may be a weaker indicator for the occurrence of cardiovascular disease, I think it may still be a good initial screening tool for individuals at risk for early metabolic dysfunction and or insulin resistance. Another I think, down the pipeline thing that I’m hoping that insurances will allow more further coverage of is genetic testing. With the advent of precision medicine, again, trying to find an issue before it happens and identify something that we can hopefully fix and prevent what genomics really allows us to do is look for variants in our genes that may predispose us to a clot formation or atherosclerotic atherosclerosis with cholesterol building up in the arteries of our heart. So I really do think that this is something we’re actively doing right now. But beyond that, I hope it starts to become a standard when we’re actually thinking about patients from a preventive perspective. Well, let’s talk about the more standard tools that we actually do use on a daily basis. Particularly, I use as somebody who focuses on lipids and prevention. And when we think about it, we know inflammatory markers do factor in so high sensitivity CRP, for example. This is an example of an inflammatory marker. And this was actually first brought to light with the Jupiter study, where we saw that those who had an elevated high sensitivity CRP and were started on a statin, irrespective of what their LDL levels may or may not have been, had lower out of cardiovascular outcomes when it came to mortality or morbidity from cardiovascular disease. So using a high sensitivity CRP which even the prevention of lipid guidelines factors in as possibly making one if they’re on the fence or should they start a statin or not, may actually help to at least further risk stratify patients. Beyond that, though, we have other markers, right? And in addition to LDL or HDL, these other lipid markers may help predict the ability for us to determine what one’s risk of cardiovascular disease in the future may be. One thing I want to stress is that low density lipoprotein is absolutely the major atherogenic lipoprotein but we know actually that 50% of people that have normal LDL still could have cardiovascular disease, and that’s where these other markers that are with all with all intents purposes come off of these LDL particles come into play. So apolipoprotein B or lipoprotein little A. So Apolipoprotein B concentration is an indirect measurement of the number of LDL particles. And it has been suggested that ApoB maybe a better measure of atherogenesis. Why? Because we know that particularly LDL, especially when your triglyceride levels are above 200, may not be accurate because that LDL may be actually carrying more triglycerides and it actually does the LDL particle. So because ApoB 90% of the time equates with the actual LDL particle, if you have an elevated, it will be you’re probably more at risk of having a future cardiovascular that the same way. Now we’re thinking about really focusing in on non HDL as opposed to LDL, because that tends to reflect cholesterol that contains all ApoB containing particles. But beyond ApoB, what about lipoprotein, little A. It’s a lipid rich particles similar to LDL. And one thing that’s important to highlight is that in lipoprotein little A, it has the addition of ApoA and that actually makes it Plasminogenic meaning it’s more thrombotic. In addition to atherogenic and patients that we would be checking lipoprotein little A on are usually people that have a very strong family history and a first degree relative of premature cardiovascular disease. Beyond that, if we had a patient who was very young at the time of their cardiovascular event, we may consider also checking lipoprotein little A. Now beyond these laboratory data, we have other tools that the guideline suggests to better risk stratify patients. One could be something called an ankle brachial index, where we check the blood pressure differential in the upper extermities as compared to lower extremities. But we also have a calcium score. And a calcium score, I think has really changed the course of actually risk stratifying patients because what it is, is just an X-ray of your heart that allows us to see if there’s any calcium, which is plaques that’s calcified and hardened over that may be present because by definition that patient then has subclinical cardiovascular disease. And we know that the guidelines even give us guidance. Right? So if you have someone with a calcium score above 100 or above the 75th percentile, above the 75th percentile being actually a high risk group, it’s reasonable to initiate a statin. If the calcium score is zero, it’s actually reasonable to hold off on the standard as long as they have no evidence of diabetes or a very strong family history of premature heart disease. But again, I think the bulk of what these guidelines talk about is the fact that we need to have a more fluid patient provider conversation where we’re figuring out beyond just the numbers. Do you have any of these risk enhancers, including your ethnicity, including the social determinants that we talked about? And as you do, maybe let’s have a better conversation of what your actual risk profile may be. So in terms of my summary, and these are really my final thoughts, when it comes to race and ethnicity, it’s really a complex combo like mixture of psychosocial factors, poverty, disadvantage, socioeconomic status and suboptimal education that may factor in. But beyond that, when it comes to gender, we know that it’s that same complex and general mixture of under representation in research trials, atypical symptoms. You know, having somebody with a unique pathophysiology or lack of equitable use of guidelines or active management, but most importantly, is that pervasive systemic problem like health care disparities that are so much larger than the individual and perceived discrimination, and it’s rooted in institutions. And I think for me, utilizing the risk enhancers may be one step forward in better and utilizing a better tool to really look at these particular patients, these vulnerable populations. But there are limitations when it comes to these risk enhancers from environment, behavior and psychosocial factors. And I think that even for us in America, maybe we need to factor those in as they’re doing in Europe when it comes to better risk stratifying patients, at the end of the day, not just for all of us, but most importantly for the most vulnerable populations, which again include black women in the United States of America. And with that, I always like to end with this amazing quote from Dr. Martin Luther King Jr, who I think says it the best. “Of all the forms of inequality, injustice in health care is the most inhumane.” And I think if you learn anything from my talk today, it’s that this is central. But as long as we acknowledge it and hopefully work collectively to change it, we will hopefully see improvements in these most vulnerable patient populations. So with that, thank you very much. And I’m open to any questions you may have. Wow, that was really wonderful. Thank you so much, Dr. Bond. A lot of questions coming in and I’ve kind of grouped them in terms of topics. Okay. So one of the topics that had come up was really where does this risk classification start? I mean, you are a prevention focused cardiologist, but can you speak to a little bit about how the role of the PCP is in in this risk stratification? At what point do they send a cardiologist? Where does really this this management occur? Yeah, that’s a wonderful question because we honestly want to even start this management in the pediatric community. I have many hats and one of my hats is one of the co-chairs of our Women’s and Children’s Committee for the Association of Black Cardiologists. And the reason I wanted to be a co-chair of that was because we’re working with pediatricians to try to get the education out there to the younger youth that, hey, heart disease is preventable 80% of the time. The only way for us to ensure that is for you to know what your risks are. And the reason it’s preventable 80% of the time has a lot to do with lifestyle. What we eat, the amount of activity that we do if we smoke or we don’t, if we drink or we don’t in access. So with that, I think it’s important ideally for us to start in childhood. But when it comes to adulthood, as anyone above the age of 20 needs to have what’s called a wellness check, if you’re female versus male. What that wellness check is, is at least once a year, you’re going to your clinician, you’re getting your blood pressure checked, you’re getting your cholesterol checked, you’re getting your blood sugar checked. They’re looking at your body mass index, which allows us to figure out if your weight is appropriate for your height. They’re talking to you about physical activities, because if you’re able to maintain a healthy lifestyle as a young adult, you’re going to help predict better outcomes for you in the future. And what I one more important thing I would say is that if you have a strong family history of heart disease, one, it’s important to figure out what exactly that entailed. Who in your family have that history? And beyond that, making sure that the doctor is aware of it, Because beyond the standard testing, we may want to do further testing thereafter. Wonderful. Thank you. And you talk a lot about the specific group of black women who are specifically at a higher risk. And it brings me back to a letter by the American College of OB-GYNs highlighting how so many women are using their OB-GYNs as their PCP. So can you talk a little bit about the role of of how the OB-GYNs and PCPs can really work together to help provide this type of education and screening to know which of these women need to go for further evaluation? Absolutely. So the American College of Obstetrics and Gynecology actually released a position paper with the American Heart Association. It was about three years back now where they big knowledge, the fact that, yes, these young women are being seen predominantly by their GYNs or they’re OBs. So it’s an opportunity for the GYNs and OBs to identify the traditional risk factors, but more importantly, identify any of those adverse pregnancy outcomes that I talked about. If during their pregnancy they had gestational diabetes or hypertension or pre-eclampsia or premature labor, we may be needs to get them into the hands of a cardiologist. Beyond that, it’s important that those patients are being monitored at least once a year. With all the things I talked about, the cholesterol, the blood pressure, making sure that they’re maintaining a healthy lifestyle because those patients that are at the greatest risk. And the reason this is important is because a pregnancy is a stress test, but it’s also, more importantly, a window to your future health. So I work very closely with obstetricians in my health system, and even beyond that, when it comes to the national societies I sit on to really figure out how can we make this the standard of care because we have to target those women. Right? I showed the graphs, it really emphasized the fact that black women in America between the ages of 35 to 54 are having the highest rates of cardiovascular mortality. We need the gynecologist. We need the obstetrician to get them into the proper hands so that way we can reduce these disparities in outcomes. Thank you so much. And that kind of leads us into the next question that was asked by one of the viewers is regarding a recent study in JAMA came out assessing risk factors that lead to early incidents of CHD. So essentially it found that in women the strongest predictor was insulin resistance and diabetes, especially in those under 55. You talk a little bit about a metabolic risk panel highlighting the importance of really looking at insulin resistance as early markers for for this metabolic dysfunction. Can you can you paint a picture about how diabetes and CVD go hand in hand and why it’s important to look at them? Absolutely. So we know that diabetes is actually considered a CVD risk equivalent. And with that, why is it because when you have diabetes, particularly in poorly controlled diabetes, you know that the glucose or the blood sugar that’s in the in the artery itself or in the blood in the blood circulation itself can actually cause damage, premature damage to the artery. What it does is it leaves that artery vulnerable. So it actually starts to build up with that atherosclerosis, that plaque. So when it comes to diabetes, getting an early diagnosis is most important. But we actually want to go even beyond getting an early diagnosis of diabetes. We want to start in the pre-diabetic range because we have an opportunity to potentially change one’s lifestyle. Even now, we’re considering starting patients on medications if needed, right? In the pre-diabetic range, if they meet criteria for other things such as metabolic syndrome, for example. And the sole purpose of that is to help reduce those poor cardiovascular outcomes, the heart attacks, the strokes, because those patients are the highest risk group. It’s also important because as I showed to you, a third of the time patients that are diabetic and are between the ages of 40 to 75, they’re not actually started on a statin. And we need them on a statin because we know, again, that the diabetes itself is equivalent to having underlining cardiovascular disease and it’s a much higher it’s a much higher group. When we think about high risk groups, it’s a much higher risk group than even a normal patient population that may not be diabetic. Thank you so much. And you’re really tough. You really lead me into this next questions wonderfully. So the next question really revolves around treatment and social determinants of health. So. So given that reduced health literacy, access to nutritious foods access to open spaces for some patients, should the medium risk strategies of the cholesterol algorithm be applied to these select low risk individuals who can’t pursue these aggressive lifestyle modifications? What are your thoughts on that? Yes, they absolutely need to be, because those are the predominant factors of health. As I had emphasized, 60% of our health is dictated by those factors. And I really do applaud the European Society of Cardiology that they included them in their risk modifier or risk enhancer table. Now what can we do about it? And that’s where I think we as a society have to figure out, focusing in on those patient populations, making sure that they have access. And that’s of course beyond us as clinicians. But as long as we start the conversation and locally working with our social workers and other people within our own health institutions, I think that we will at least be able to provide them with some support. Beyond that, though, that’s where health literacy is important. And we know that in a lot of these vulnerable, vulnerable populations, using the community as a bridge helps. I myself work very closely with a lot of faith based, the faith based organizations or even beauty parlors, for example, to get the message out there to make sure that they trust the clinician, to make sure that they understand the importance of taking the medication. And I think that approach is really pivotal and makes so much more sense than what approach we’re doing right now. Because what we’re doing right now, unfortunately, is not really targeting these vulnerable populations. And we’re still seeing these high rates of death. I mean, that’s a great point. And really just leading with education and leading with the why and the understanding really helps to change patient behavior. So I think that’s a really key point. Thank you for bringing that up. Yes. So the next question is really, see, I lost my place here. There are so many questions for for black women facing CVD issues and intense social determinants of health factors. You mentioned that access to insurance. So the question specifically is does access to Medicaid have a better impact versus marketplace insurance due to the less cost sharing factors? So access to any form of insurance, we use Medicaid because that’s, of course, when we think about our most vulnerable populations, sometimes socioeconomics does factor in and this has been looked into beyond Medicaid, though, including commercial insurance. I think having access to any form of a sufficient health care empire is what is going to at the end of the day, help us get improvement in the numbers that we’re seeing. Mm hmm. Wonderful. Thank you so much. So do you think the pandemic has negatively impacted the outcomes of cardiovascular events for many folks out of work or indoor being, quarantine, being indoors? How do you think that this is going to result in any accumulation of CV events in the future? Yeah. So as I briefly alluded to in my presentation, I was just actually looking at a report today and they had mentioned that in 2020 black males lost three years of life in six months and black women nearly two and a half years. So that again means that the life expectancy numbers that I showed are now down by two and a half to three years, and that’s just in 2020 as a result of the pandemic. Now, what I fear is that beyond the pandemic, the fear of a lot of our patients going to the hospital, right, because of the fact that they fear that they may get the virus in the hospital, despite that not actually being factual. The fear of other things with which we have heard within the news media and things of that nature, I think has factored into a lot of delays in care, but most importantly, a decreased amount of preventive care and prevention and heart disease. What’s important for us to understand, and what I always tell my patients is that heart disease doesn’t stop during a pandemic. It’s still the leading cause of death. And my fear is that once we actually see the numbers for the fiscal 2021, you know, we’re likely going to see that the rates of mortality have steadily increased. But we have an opportunity to fix that one way, at least in terms of making sure that this pandemic is, you know, under control, is mitigated, is again, thinking about social distancing, wearing masks. Absolutely. If you’re eligible, getting the vaccination. But beyond that, making sure that you’re following up with your health care providers as you should, if you have risk factors, but beyond, even if you don’t have risk factors, making sure you’re still getting that preventive care, I think that’s definitely key. And one of the there’s a couple of questions that have come in about how can we better reach those who are at the lower socio economic population or the minority population to to get them into the office. Do you have any suggestions? You mentioned a little bit about grassroots. You know, really getting going into the communities. Is that. Yeah, I really think that that is a very effective approach. Grassroot effort is again in terms of reaching out to community leaders that they trust and really having them pave that trust and that communication is one way. But beyond that, you know, I do a lot of speaking engagements for communities because I want them to identify myself as an African American cardiologist. And I think that data has definitely, without a question, show that there is a patient physician concordance and improvement in overall outcomes. Right. So if somebody sees somebody who empathizes with them, identifies with their background, they’re more likely to have that level of trust, have that level of ability and willingness to want to comply with the standards. When it comes to the cardiology field, I am a very unique brand because of the fact women, actually black women, make up only 2% of the population. So it’s important that there are organizations out there like the Association of Black Cardiologists and even American Heart Association, the American College of Cardiology. They want to expand and diversify the field because we know that that’s one part of improving these outcomes. But in the interim, partnering with those trusted leaders at the grassroots, I think are going to be really impactful. Yeah, and you had touched on a couple of points about how it’s important to choose a PCP, who or whoever you’re after is of someone that you trust. And so one of the questions was about statin therapy. And is it a is it a clinician like a clinician provided statin is missing those those minorities, or is it that they’re recommending them but just not pushing enough or, you know, is it on the patient that doesn’t actually fulfill the statins? Yeah. So that those those specific trials did not look at the underlining root cause. But I personally can say it’s probably multifactorial. It’s the busy clinician who may not be taking the time to explain, most importantly, explain why this statin is necessary. But beyond that, what they did look at was the patients that were prescribed statins. They were not actually prescribed the appropriate dose of statins, much more likely if they were African-American versus not. And that, I think, is on us as clinicians. We have to be aware of the fact that if we have a high risk population because of their risk equation or because they have underlying atherosclerotic heart disease, we have to be prescribing them high intensity statins and we have to be following the LDL levels to make sure that they’re reaching the goals or at least below the thresholds that they should be. And that was looked into. But to answer the original question, I think it’s a multitude of reasons, again, at the end of the day stems from having that really important and impactful patient clinician conversation. I mean, then I know we only have a couple of minutes left, so I’m hoping with this last question, you can kind of give us and all the attendees here today, thank you for your time, but give us some takeaways about how exercise and weight loss and prevention of cardiovascular disease can help to lower a lot of the risk factors, things that you recommended your patients to do. You know, any takeaways would be Absolutely. And that’s, I think, the most important thing, right? Medications are not the first line we want to start when it comes to, again, our low risk, even our borderline and even sometimes our intermediate risk group with that aggressive lifestyle. And what the American Heart Association recommends is at least 150 minutes per week of some form of moderate cardio or 75 minutes per week of vigorous cardio. Beyond that, though, we know that a plant predominant diet is really the healthiest diet. So a lot of examples of that include the Dash diet or the Mediterranean diet that has been scientifically proven to lower one’s risk of cardiovascular disease. That includes a diet low in saturated fat or trans fat. So a lot of red meat, but increasing your legumes or a whole wheat or grains, you’re you’re you know, you’re nuts, you’re healthy fat, such as the omega three fatty acids, which a lot of the time we get from oily fish like salmon, we can also beyond fish, can get it from kale, even our avocados and things of that nature. But most importantly I think for me, I always like to tell my patients, and especially in America, that moderation is so important and you can be eating the healthiest of meals. But if you’re eating too much of it, it’s going to lead to excess weight. It’s going to be bad for you in the end. So we want to make sure that there’s that balance. We want to talk about excess alcohol without a question. We want to talk about, you know, increasing our water intake and all of that collectively is part of the prescription. I talk about this with my patients. The diet is a prescription, their exercise plan is a prescription. So they understand the importance and significance of it, because that can be a factor of medication or no medication at the end of the day. Very good. Very good. Thank you so much for that. And I hope everyone had enjoyed the talk. There were so many questions. And as much as we would love for Dr. Bond to stick around all day and answer them, we very much appreciate her time today. And with that, again, thank you, Dr. Bond, for taking time out of your busy schedule to share your knowledge with us to our many participants. Thank you so much for joining as well. If you registered with Zoom, you’ll receive an email next week with a link to an online survey that you need to complete in its entirety. If you have registered on behalf of a group of colleagues, please forward that survey link to them when you receive it. And again, thank you, Dr. Bond for taking time out of your busy schedule and thank you to all the attendees. Thank you very much and have a great rest of your day. Thank you. Bye bye. Bye.