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Racial disparities in heart failure explained

Experts hopeful that findings could help identify individuals who might benefit from earlier intervention

An older Black female patient with a young female doctor
African American men and women have disproportionately high rates of heart failure, a significant health disparity that persists despite considerable advances in cardiovascular care.

DALLAS – Jan. 14, 2020 – Researchers at UT Southwestern have uncovered evidence that the higher prevalence of “malignant” enlargement of the heart among blacks contributes to the higher incidence of heart failure in this population. The new study is published online in the journal Circulation.

Left ventricular hypertrophy or LVH is the enlargement and thickening of the muscular wall of the left ventricle of the heart, the lower left chamber. This thickening can be detected on an electrocardiogram or with imaging tests like an echocardiogram. LVH can occur in several forms. In about half of cases, LVH occurs without other evidence of heart damage or stress, and in these cases the prognosis appears to be benign and similar to people without LVH. In contrast, in the other half of cases, when LVH occurs together with signs of damage or stress to the heart muscle, the course is malignant and associated with a markedly higher risk of heart failure.

James de Lemos, M.D.
James de Lemos, M.D.

“Malignant LVH is easily identifiable with widely used tests in the clinic, so now that we’ve found this association, we are hoping to identify patients with higher risk for heart failure earlier, when preventive interventions can have a greater impact on future risk,” says James de Lemos, M.D., a professor of internal medicine at UT Southwestern Medical Center.

Previous studies described a malignant type of left ventricular hypertrophy but did not include enough participants to enable researchers to conclude whether the observed differences in malignant LVH contribute to a higher risk of heart failure for black versus white individuals. So the UT Southwestern researchers pooled data from three biracial cohort studies – the Atherosclerosis Risk in Communities (ARIC) Study, the Dallas Heart Study, and the Multi-Ethnic Study of Atherosclerosis (MESA) – to test the hypothesis that malignant LVH may contribute to disparities in heart failure risk.

Combined, the three studies encompassed health data from more than 26,000 people living in North Carolina, Mississippi, Minnesota, Maryland, Illinois, California, New York, and Texas. All three studies included height, weight, blood pressure, and blood test results as well as electrocardiogram results, a measure of the electrical activity of the heart. For this study, the researchers excluded participants with cardiovascular or kidney disease and those who were not self-identified as white or black, which resulted in a study group of 15,710 participants. The median age was 57 years with 56 percent female, 32 percent black, and 36 percent with hypertension.

Individuals with left ventricular hypertrophy were identified by ECG, and the malignant form of LVH was further defined as having abnormal blood marker levels reflecting injury or stress to the heart muscle. For blood markers, the researchers looked for abnormal high-sensitivity cardiac troponin levels or abnormal N-terminal pro-brain natriuretic peptide levels.

Using these characteristics, the team classified all study participants into groups based on whether they had ECG-LVH and abnormal blood markers. Then they determined how many of these participants had been hospitalized or had died due to a heart failure event in the 10 years of follow-up.

Nine percent of participants had LVH, 27 percent had abnormal cardiac troponin, and 21 percent had abnormal pro-brain natriuretic peptide levels. Of those participants with LVH, 47 percent had normal biomarker levels, 37 percent had one abnormal biomarker, and 15 percent had abnormal levels of both biomarkers.

The team found that participants with malignant LVH were older, more likely to be male, with diabetes, hypertension, and high blood pressure compared with those without LVH or those with LVH but normal blood tests. They also found that the prevalence of malignant LVH was three times higher among black men and women compared with white men and women.

Heart failure occurred in 512 participants (3.3 percent) over the 10 year study period. Of those, 56 percent were men and 39 percent were black. The rates of heart failure were highest for black men, intermediate for white men and black women, and lowest among white women. Of the participants with malignant LVH, 13 percent developed heart failure compared with 2.7 percent in the group with LVH and normal biomarkers.

Alana Lewis, M.D.
Alana Lewis, M.D.

“Our study helps explain why African American men and women have disproportionately high rates of heart failure, a significant health disparity that persists despite considerable advances in cardiovascular care,” says Alana Lewis, M.D., a cardiology fellow at UT Southwestern Medical Center and lead author of the study. “We hope these findings can help cardiologists identify those at higher risk for developing heart failure and intervene earlier.”

Additional UT Southwestern researchers who contributed to the study are: Colby R. Ayers, M.S.; Ian Neeland, M.D.; Ambarish Pandey, M.D.; Mark H. Drazner, M.D., M.Sc.; and Jarett D. Berry, M.D.

Neeland has received honoraria, consulting and speaker’s bureau fees, and travel support from Boehringer-Ingelheim/Lilly Alliance, has received a research grant from Novo Nordisk, and has been a member of the scientific advisory board of AMRA Medical. Christie Ballantyne, M.D. is a consultant for Abbott and Roche and is named on provisional patent No. 61721475 titled “Biomarkers to Improve Prediction of Heart Failure Risk” filed by Baylor College of Medicine and Roche. Vijay Nambi, M.D. is an investigator on provisional patent No. 61721475 titled “Biomarkers to Improve Prediction of Heart Failure Risk” filed by Roche and Baylor College of Medicine. Tiffany Powell-Wiley, M.D. is funded by the Division of Intramural Research of the National Heart, Lung, and Blood Institute and the Intramural Research Program of the National Institute on Minority Health and Health Disparities. Berry discloses research support from Abbott. He is also a national coordinator for the STRENGTH trial. Stephan L. Seliger, M.D. receives grant support from Roche Diagnostics. Christopher R. deFilippi, M.D. has received consulting, honorarium, and royalties from Siemens Healthcare Diagnostics, Alere/Abbott Diagnostics, Fujirebio, Radiometer, Roche Diagnostics, Ortho Diagnostics, Metabolomics, Quintiles, WebMD, and UpToDate. He has also received research grants from Siemens Healthcare Diagnostics, Roche Diagnostics, Abbott Diagnostics, Ortho Diagnostics, and Fujirebio. De Lemos reports grant support from Roche Diagnostics and Abbott Diagnostics, consulting fees from Roche Diagnostics, Abbott Diagnostics, Ortho Clinical Diagnostics, Quidel Cardiovascular Inc., Novo Nordisk, Amgen, Regeneron, and Esperion. Seliger, DeFilippi, and de Lemos have a patent pending (U.S. patent application No. 15/309,754) titled “Methods for Assessing Differential Risk for Developing Heart Failure.” The other authors have no relationships to disclose.

The Dallas Heart Study was supported by grants from the Donald W. Reynolds Foundation and the National Center for Advancing Translational Sciences (UL1TR001105). The Atherosclerosis Risk in Communities study has been funded in whole or in part with federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, and Department of Health and Human Services, under contract Nos. HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, and HHSN268201700004I. MESA was supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC95166, N01-HC-95167, N01-HC-95168, and N01-HC-95169 from the National Heart, Lung, and Blood Institute and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Advancing Translational Sciences (NCATS).

About UT Southwestern Medical Center

UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty has received six Nobel Prizes, and includes 22 members of the National Academy of Sciences, 17 members of the National Academy of Medicine, and 14 Howard Hughes Medical Institute Investigators. The full-time faculty of more than 2,500 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in about 80 specialties to more than 105,000 hospitalized patients, nearly 370,000 emergency room cases, and oversee approximately 3 million outpatient visits a year.