Chapter 12: Heart Failure in Minorities

PATIENT CASE

Ms. Jones is a 64-year-old African American woman with a history of hypertension (HTN), type 2 diabetes mellitus, and remote tobacco usage who works as a teller at a bank. She presents with complaints of increased dyspnea on exertion after walking 25 feet. She has noticed bilateral lower extremity edema and has been sleeping in a recliner on the first floor of her home rather than in her bed on the second floor for the past month because of shortness of breath when climbing stairs. Should the diagnosis of heart failure (HF) and management be based upon the patient’s race and ethnicity?

OVERVIEW

The prevalence of HF in the United States is on the rise, and it disproportionately affects racial/ethnic minorities.^1-5 Currently 5.1 million individuals in the United States have HF.⁶ While the risk of developing HF is 1 in 5 after age 40 years, the prevalence is expected to approach 46% in 2030.^6,7 African Americans have the highest risk of developing HF (4.6 per 1000 person-years), followed by Hispanic/Latinos (3.5 per 1000 person-years), Caucasians (2.4 per 1000 person-years), and Chinese Americans (1.0 per 1000 person-years).^6,7 With the growing populations of racial/ethnic minorities in the United States, including Hispanics and Asians, these minorities will represent an emerging number of HF patients.^8,9 This chapter reviews the burden of HF on different racial and ethnic groups in the United States and appropriate management.

ETIOLOGY AND PATHOPHYSIOLOGY

The etiology of HF differs based on racial and ethnic backgrounds.¹⁰ Ischemic disease and HTN are the most common causes of HF in the general population and should be assessed for independent of race and ethnicity upon diagnosis.^1,5,10 In the Multi-Ethnic Study of Atherosclerosis, the development of HF was linked to coronary calcification with Caucasians having the highest prevalence followed by African Americans, Hispanics, and then Chinese Americans.⁷ African Americans who developed HF more commonly had left ventricular (LV) hypertrophy, HTN, diabetes, and obesity, whereas Chinese Americans had rare incidence of LV hypertrophy.^6,7,11 These differences may also be attributed to physiologic (salt sensitivity, vascular reactivity, nocturnal dipping in blood pressure, renin angiotensin-aldosterone activation system), genetic, and environmental factors, which will be discussed later in this review.^10,12,13 Unfortunately many of the large HF clinical trials have failed to include sufficient numbers of racial and ethnic minorities, which limits precision-based care (Table 12-1).¹⁴