Announcing The Lancet Regional Health-Europe commission on inequalities and disparities in cardiovascular health
Authors: Raffaele Bugiardini, Chris P. Gale, Martha Gulati, Sonia S. Anand, Angela H.E.M. Maas, Nick Townsend, Viola Vaccarino, Lina Badimon, Edina Cenko, Olivia Manfrini, Pooja Jha
Journal: The Lancet Regional Health - Europe (2024)

The continued and widening disparities in cardiovascular health, despite overall declines in cardiovascular mortality, highlight the inequities in the distribution of advancements in cardiovascular care. These inequities disproportionately affect certain groups within the population, underscoring the need for targeted efforts to ensure equitable healthcare access and outcomes for all individuals.1Woodruff R.C. Tong X. Wadhera R.K. Loustalot F. Jackson S.L. Vaughan A.S. Cardiovascular disease mortality disparities in black and white adults, 2010‒2022.Am J Prev Med. 2023; 66: 914Summary Full Text Full Text PDF Scopus (0) Google Scholar Subgroups within the population experiencing relative increases in age-adjusted mortality rates due to heart disease from 2019 to 2022 include the elderly aged 65−74 years (7.6%), those aged ≥85 years (9.2%), women (9.8%), Black adults (10.6%), American Indian or Alaska native (9.6%) and Asian or Pacific islander (12.2%).1Woodruff R.C. Tong X. Wadhera R.K. Loustalot F. Jackson S.L. Vaughan A.S. Cardiovascular disease mortality disparities in black and white adults, 2010‒2022.Am J Prev Med. 2023; 66: 914Summary Full Text Full Text PDF Scopus (0) Google Scholar Moreover, individuals with severe mental illnesses such as depression and psychosis have an approximately 35%2Vaccarino V. Badimon L. Bremner J.D. et al.Depression and coronary heart disease: 2018 position paper of the ESC working group on coronary pathophysiology and microcirculation.Eur Heart J. 2020; 41: 1687-1696Crossref PubMed Scopus (386) Google Scholar higher risk of experiencing a major cardiovascular event, and face up to five times higher risks of cardiovascular mortality and sudden cardiac death.3Nielsen R.E. Banner J. Jensen S.E. Cardiovascular disease in patients with severe mental illness.Nat Rev Cardiol. 2021; 18: 136-145Crossref PubMed Scopus (153) Google Scholar Addressing cardiovascular disease disparities in these subgroups of populations—women, ethnic minorities, elderly and those with mental health conditions—is one of the most important challenges in global public health. To address inequalities and disparities in cardiovascular health among disadvantaged populations, The Lancet Regional Health–Europe has launched a pivotal Commission dedicated to addressing these issues. This Commission is tasked with carrying out an exhaustive assessment of available data on the incidence and outcomes of cardiovascular disease, both at a global and regional level. It will offer a detailed overview of existing gaps in data and pinpoint the most achievable objectives for enhancing health outcomes. Addressing the persistent disparities in cardiovascular health, this endeavour aims to serve as a catalyst for change. It seeks to usher in a new era of equity in cardiovascular health care and research, ensuring that progress benefits all sectors of society, especially those who have been historically underserved. By focusing on comprehensive assessments and targeted interventions, the initiative is dedicated to bridging gaps in treatment and outcomes, making strides toward equal health opportunities for every individual. The decision to focus on women stems from recognizing that cardiovascular diseases often present differently in women compared to men, impacting diagnosis, treatment, and outcomes.4Cenko E. Yoon J. Kedev S. et al.Sex differences in outcomes after STEMI: effect modification by treatment strategy and age.JAMA Intern Med. 2018; 178: 632-639Crossref PubMed Scopus (191) Google Scholar While women are generally perceived to have a lower risk of coronary heart disease mortality due to a lower disease prevalence, data from the past two decades reveal higher mortality rates among women, particularly following myocardial infarction.5Hochman J.S. Tamis J.E. Thompson T.D. et al.Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators.N Engl J Med. 1999; 341: 226-232Crossref PubMed Scopus (749) Google Scholar Emphasizing women's cardiovascular health is crucial for addressing historical gaps in research and healthcare practices that have overlooked these differences. Identifying the precise causes of outcome disparities between women and men is challenging due to women's underrepresentation in cardiovascular research and clinical trials.6Vogel B. Acevedo M. Appelman Y. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438Summary Full Text Full Text PDF PubMed Scopus (508) Google Scholar This underrepresentation has resulted in significant sex-based disparities in the treatment of atherosclerotic cardiovascular disease, with research revealing distinct pathophysiological and risk factor profiles for men and women.6Vogel B. Acevedo M. Appelman Y. et al.The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.Lancet. 2021; 397: 2385-2438Summary Full Text Full Text PDF PubMed Scopus (508) Google Scholar The commission will analyse how sex and gender differences influence cardiovascular disease risk factors, comorbidities, symptom presentation, diagnostic methods, treatment approaches, and outcomes. The inclusion of neglected ethnic and racial groups emphasizes the heightened burden of cardiovascular disease they endure.7Anand S.S. Razak F. Davis A.D. et al.Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.Int J Epidemiol. 2006; 35: 1239-1245Crossref Scopus (66) Google Scholar,8Kist J.M. Smit G.W.G. Mairuhu A.T.A. et al.Large health disparities in cardiovascular death in men and women, by ethnicity and socioeconomic status in an urban based population cohort.eClinicalMedicine. 2021; 40101120Summary Full Text Full Text PDF Scopus (9) Google Scholar In the United States, Black individuals face a disproportionately higher burden of cardiovascular disease risk factors such as hypertension and obesity and are more than twice as likely to die of cardiovascular disease, relative to White adults; American Indians are also at an elevated risk of coronary heart disease.9Health, United States spotlightRace and ethnic disparities in heart disease.2019Google Scholar In Europe, persistent disparities are evident. For instance, Surinamese and Antillean populations in the Netherlands and South Asian individuals in the UK experience higher coronary heart disease mortality rates compared to their White counterparts.7Anand S.S. Razak F. Davis A.D. et al.Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.Int J Epidemiol. 2006; 35: 1239-1245Crossref Scopus (66) Google Scholar,8Kist J.M. Smit G.W.G. Mairuhu A.T.A. et al.Large health disparities in cardiovascular death in men and women, by ethnicity and socioeconomic status in an urban based population cohort.eClinicalMedicine. 2021; 40101120Summary Full Text Full Text PDF Scopus (9) Google Scholar,10Lee K.K. Norris E.T. Rishishwar L. et al.Ethnic disparities in mortality and group-specific risk factors in the UK Biobank.PLOS Glob Public Health. 2023; 3e0001560Crossref Google Scholar These disparities underscore the critical need for culturally sensitive interventions and the dismantling of systemic barriers to healthcare that perpetuate these inequalities.5Hochman J.S. Tamis J.E. Thompson T.D. et al.Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIb investigators.N Engl J Med. 1999; 341: 226-232Crossref PubMed Scopus (749) Google Scholar Addressing cardiovascular health disparities necessitates a deep understanding of several foundational concepts, including the definitions of ethnicity, race, and indigeneity, and their intersection with social disadvantages, education, and gender. The Commission will provide an overview of inequalities in cardiovascular health screening, diagnosis, and treatment, with a focus on diverse populations distinguished by ethnicity and race. By exploring the intersections of racial or ethnic identity, gender, and social disadvantages, the Commission aims to identify and propose innovative solutions to narrow the health equity gap. Focusing on the elderly addresses the increasing prevalence of cardiovascular disease in aging populations and their specific needs for specialized care.11Rodgers J.L. Jones J. Bolleddu S.I. et al.Cardiovascular risks associated with gender and aging.J Cardiovasc Dev Dis. 2019; 6PubMed Google Scholar Aging significantly increases cardiovascular disease risk, with a notable portion of acute coronary syndrome hospitalizations and deaths occurring in those over 65.11Rodgers J.L. Jones J. Bolleddu S.I. et al.Cardiovascular risks associated with gender and aging.J Cardiovasc Dev Dis. 2019; 6PubMed Google Scholar Age-related changes in cardiovascular physiology and increased comorbidity rates affect disease presentation and treatment responses. As the population ages, the demand on healthcare services and the need for enhanced support and tailored treatment approaches increases. Prioritizing the cardiovascular health of the elderly is crucial to enhance their quality of life as called for by the UN's Decade of Healthy Ageing.12World Health OrganizationUN decade of Healthy ageing: plan of action.2020https://www.who.int/initiatives/decade-of-healthy-ageingGoogle Scholar The commission will explore the escalating cardiovascular disease burden among older adults, with a focus on prevention, treatment, and strategies to uphold their physical and mental well-being. In light of the intricate link between mental well-being and cardiovascular health, this Commission will also focus on individuals with mental health conditions or those exposed to psychological stress.13Song H. Fang F. Arnberg F.K. et al.Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study.BMJ. 2019; 365l1255PubMed Google Scholar Mental health conditions such as depression and anxiety can increase cardiovascular disease risk by influencing behavior, stress responses, and health practices.13Song H. Fang F. Arnberg F.K. et al.Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study.BMJ. 2019; 365l1255PubMed Google Scholar Conversely, experiencing cardiovascular disease is a stress-inducing event, exacerbating pre-existing mental health conditions and/or leading to new conditions such as anxiety disorders, depression. Recognizing stress as a shared risk factor for mental health and cardiovascular issues advocates for integrating stress management into preventive healthcare. The aim of the Commission encompasses summarizing current research to pinpoint gaps in understanding cardiovascular health among those with mental health conditions developing strategies to enhance their cardiovascular outcomes, raising awareness about the unique obstacles they face, and delineating future research priorities. The establishment of a Commission on Inequalities and Disparities in Cardiovascular Health by The Lancet Regional Health–Europe is crucial for several compelling reasons. Firstly, the Commission would provide a vital platform for understanding the root causes of cardiovascular health disparities and identifying the specific needs and barriers faced by various groups, including women, the elderly, specific ethnic/racial groups, and individuals with stress or mental illness. Secondly, it would play a pivotal role in informing policy development aimed at reducing health inequalities. By pinpointing high-impact areas for intervention, policies can be tailored to ensure that funding and resources are directed towards those most in need and where they can have the greatest impact. Thirdly, the commission can serve as a catalyst for collaborative efforts to address cardiovascular health disparities through advocacy and awareness raising. This collaborative approach ensures that policy recommendations are rooted in scientific evidence while also incorporating practical aspects and the lived experiences of those most impacted by health disparities. By tackling the key challenges (Fig. 1) associated with cardiovascular health disparities stemming from sex and gender differences, mental health status, aging, ethnicity, and race, this commission will advance the overarching objective of attaining the three UN Sustainable Development Goals on good health and wellbeing (SDG 3), gender equality (SDG 5), and reduced inequalities (SDG 10). The Lancet Regional Health Europe Commission on Inequities and Disparities in Cardiovascular Health is chaired by Professor Raffaele Bugiardini, University of Bologna (Italy), Co-Chairs are Professor Chris P Gale, Leeds Institute of Cardiovascular and Metabolic Medicine at the University of Leeds (UK), and Dr Martha Gulati, Barbra Streisand Women's Heart Center Smidt Heart Institute, Cedars-Sinai Medical Center Los Angeles CA (US). The Commissioners are grouped in four Working Groups: women, ethnic minorities, elderly, and mental health conditions. Each of the Working Groups has a coordinator. See the list of contributors and Commission organization in the Appendix. RB, SA, AM, NT, VV and PJ contributed to study design and editing of the manuscript. CG, MG, LB, EC and OM contributed to editing of the manuscript. RB reports participation on the data safety monitoring board of Aptabio Therapeutics. CG reports funding from Horizon 2020, grants or contracts from Alan Turing Institute, British Heart Foundation, National Institute for Health Research, Abbott Diabetes, Bristol Myers Squibb and European Society of Cardiology, consulting fees from AI Nexus, AstraZeneca, Amgen, Bayer, Bristol Myers Squibb, Boehrinher-Ingleheim, CardioMatics, Chiesi, Daiichi Sankyo, GPRI Research B.V., Menarini, Novartis, iRhythm, Organon, The Phoenix Group; fees from AstraZeneca, Boston Scientific, Menarini, Novartis, Raisio Group, Wondr Medical and Zydus; participation on the data safety monitoring board or advisory board of DANBLCOK trial and TARGET CTCA trial; fiduciary role as Deputy Editor: EHJ Quality of Care and Clinical Outcomes, NICE Indicator Advisory Committee, and Chair ESC Quality Indicator Committee: stock or stock options of CardioMatics; and receipt of other services from Kosmos device. MG reports unpaid leadership or fiduciary role as President of The American Society for Preventive Cardiology. SSA reports leadership or fiduciary role as Associate Vice-President of Global Health; McMaster University and Department of Medicine's Associate Chair of Equity and Diversity; McMaster University; Other financial or non-financial interests: Tier 1 Canada Research Chair in Ethnicity and CVD, Chair in Population Health of Heart & Stroke Foundation and Foundational and grant from Canadian Institutes of Health Research. AHEMM decares consulting fees from Philips and Organon. The other authors have no relevant conflicts of interest to declare related to this manuscript. Download .docx (6.32 MB) Help with docx files Appendix