Doctors have long relied on a few key patient characteristics to assess risk of heart attack or stroke, using a calculation that takes into account blood pressure, cholesterol, smoking and diabetes , as well as demographic data: age, gender and race.
Now the American Heart Association is taking race out of the equation.
The overhaul of the widely used cardiac risk algorithm is a recognition that, unlike gender or age, racial identification is not itself a biological risk factor.
The scientists who modified the algorithm decided from the start that race itself had no place in the clinical tools used to guide medical decision-making, even though race could serve as an indicator of certain circumstances. social, genetic predispositions or environmental exposures that increase the risk of cardiovascular disease. disease.
The revision comes amid growing concern about health equity and racial bias within the U.S. healthcare system, and is part of a broader trend to remove race from a variety of clinical algorithms.
“We shouldn’t use race to determine whether or not someone gets treatment,” said Dr. Sadiya Khan, a preventive cardiologist at Northwestern University’s Feinberg School of Medicine who chaired the editorial board of the American Heart statement. Association, or AHA
The press release was published Friday in the association’s newspaper, Circulation. An online calculator using the new algorithm, called PREVENT, is still in development.
“Race is a social construct,” Dr. Khan said, adding that including race in clinical equations “can cause significant harm by implying that it is a biological predictor.”
That doesn’t mean Black Americans aren’t at greater risk of dying from cardiovascular disease than white Americans, she said. That is the case, and the life expectancy of Black Americans is also shorter, she added.
But race has been used in algorithms as a proxy for a range of factors that work against Black Americans, Dr. Khan said. Scientists are not clear on what all these risks are. If they were better understood, “we could respond to them and work to change them,” she said.
Cardiac risk assessment has also been improved in several other significant ways. It can be used by people from the age of 30, unlike the previous algorithm, which was only valid for people aged 40 and over, and which estimates the total cardiovascular risk over 10 and 30 years.
The assessment has been redesigned, for the first time, to estimate an individual’s risk of developing heart failure, not just a heart attack or stroke. This is important because heart failure has increased in recent years with the aging of the population and the high prevalence of obesity. This disease can lead to a serious deterioration in the quality of life.
Also for the first time, the new calculator takes kidney function into account when predicting risks, because kidney disease puts people at higher risk of heart disease, heart attack, heart failure and accidents cerebrovascular.
In recent years, the close link between cardiovascular disease, kidney disease and metabolic diseases (which include type 2 diabetes and obesity) has been increasingly recognized. Last month, the association’s scientific advisors defined a new disorder called cardiovascular-kidney-metabolic syndrome, or CKM.
“CKM is associated with significant premature mortality, primarily due to cardiovascular disease,” said Dr. Chiadi Ndumele, a cardiologist at Johns Hopkins Medicine and also an author of the new scientific statement.
“This is disproportionately present when there are negative social determinants of health,” he said, which include “the social context in which we eat, work, learn and play.”
The new equation also provides options to include a measure of blood sugar control, called hemoglobin A1C, in people with type 2 diabetes, and to incorporate a factor called the social deprivation index, which includes poverty, unemployment, education and other factors.
The changes are “great news,” said Dr. David S. Jones, a psychiatrist and professor of the history of medicine at Harvard who wrote a paper on the use of race in myriad decision-making algorithms. medical decision, published in the New York Times. Journal of Medicine of England in 2020.
The article describes how race has been used in a wide range of clinical algorithms used to make medical judgments about conditions as diverse as urinary tract infections, vaginal birth after cesarean section, breast cancer, pulmonary function and renal function.
“It has been extremely gratifying to see how medical thinking has evolved on this issue over the past three to five years,” said Dr. Jones.
Although there are racial gaps in many health measures, scientists need to conduct research to understand exactly what causes these differences, he said, adding: “You can’t just divide the world between Blacks and whites and saying all whites get this and all blacks get that.
Implementing changes can be difficult, however, he said.
Two years ago, a scientific working group from the National Kidney Foundation and the American Society of Nephrology called for abandoning a measure of kidney function that adjusted results based on race, often giving the impression that black patients were less sick than they are and leading to delays in treatment.
Within 18 months, about 65 percent of all labs had adopted the new approach, said Dr. Neil Powe, chief of medicine at Zuckerberg San Francisco General Hospital and professor of medicine at the University of California at San Francisco.
Dr. Powe said he shares a concern raised by the authors of the AHA scientific statement: What exactly is at the root of racial health disparities?
“I have said many times that we need to do more research to understand what the breed is capturing and what its surrogate is,” Dr. Powe said.
Many doctors are unsure whether and to what extent their patients are experiencing social stressors that affect their health. Research on maternal deaths, for example, has shown that wealth and higher education do not offset the adverse health effects associated with being black in America.
Although wealthier mothers and their babies were more likely to survive a year after giving birth, a California study found that the same was not true for black women: wealthier black mothers and their babies are twice as likely to die as the richest white women. mothers and their babies.