Researchers Explore How COVID-19 Affects Heart Health in Black Women

 By American Heart Association News (8/25/20)

Nearly six months into the COVID-19 pandemic, two things have become clear: The virus profoundly impacts people with heart disease and disproportionately impacts Black people. But the many manifestations of these disparities remains unclear, particularly for one group regularly left out of medical research.

"African American women are often at the intersection of the worst economic and health disparities," said Dr. Michelle Albert, a cardiologist and professor of medicine at the University of California, San Francisco. "They are a group that is often overlooked."

In a collaborative investigation with the Slone Epidemiology Center at Boston University, Albert is leading a study to look at a cohort of women enrolled in the Black Women's Health Study to determine the myriad ways in which COVID-19 is impacting them.

She said she chose to study this demographic because Black women often are at higher risk for heart disease than women in other demographic groups, and they are shouldering an excessive burden during the pandemic.

African Americans with COVID-19 are nearly three times as likely to require hospitalization than white people with the disease, according to a recent study published in the journal Health Affairs. According to statistics compiled by the nonprofit American Public Media Research Lab, Black and Indigenous people die from COVID-19 at more than three to four times the rate of white people.

Cardiovascular disease, research shows, could play a substantial role in those deaths. And for African American women especially, the risks for heart disease are high. Four out of 5 Black women are considered overweight or have obesity – the highest rate of any group in the country, according to the U.S. Office of Minority Health, and they are 60% more likely to have high blood pressure than their white counterparts.

Those risks didn't happen in a vacuum, experts say. Numerous factors place greater stress on African American women that can affect their health.

"The United States has a longstanding history of disparities in education, income, wealth and housing, and these factors, or social determinants of health, disproportionately affect African Americans – and African American women in particular," said Yvonne Commodore-Mensah, assistant professor at Johns Hopkins School of Nursing and the School of Public Health in Baltimore. She also is a faculty member at Johns Hopkins' Center for Health Equity.

"These social determinants of health result in a burden of underlying risk factors for COVID-19: high blood pressure, diabetes, overweight and obesity. These risk factors increase the risk for severe COVID-19 illness and mortality."

African American women may also be more exposed to contagion, said Dr. LaPrincess Brewer, assistant professor of medicine in the Mayo Clinic's department of cardiovascular medicine in Rochester, Minnesota. "They are more likely to hold service sector jobs that increase their risk of exposure to COVID-19. They are more likely to serve as heads of household."

What's more, Albert said, "they are caregivers of multiple generations, including children and elderly relatives and extended family. And they are more likely to experience every kind of bias – medical as well as racial/ethnic biases – in housing and employment."

All of these factors multiply stress, which can impact heart health. "This pandemic has really affected the livelihood of the African American community and the ability of community members to maintain a healthy lifestyle," said Brewer. "It's largely related to the extreme burden of stressors resulting from this crisis."

But as evidence begins to emerge showing COVID-19 has a widespread, adverse impact on cardiovascular health, the data is not being collected in ways that allow researchers to look at its impact on specific demographic groups – information that could be critical in helping to identify treatments and prevention strategies for those at highest risk.

Albert's study was among a dozen recently funded by the American Heart Association to investigate heart and brain issues related to COVID-19. The AHA also created a COVID-19 CVD Registry that is working to enroll historically underrepresented groups. The registry is collecting data from thousands of COVID-19 patients nationwide to advance the work of scientists, doctors and researchers investigating the coronavirus.

Albert said she hopes her research findings pinpoint the experiences and perceptions of African American women so that targeted solutions can be developed. The research community needs to do more studies like this, those in the field say.

"When we collect data, we have to report it systematically, so we can analyze it to understand what complications may affect African American women differently than white women," Commodore-Mensah said. "Without this data, we have an incomplete picture of what affects the risk for severe COVID-19 illness and death.

"Women in general are not well represented in research studies on cardiovascular health," she said. "Compounding that, Black women are less represented than white women, for different reasons."

They may be unable to get off work to take part in clinical trial visits, she said. Or those recruiting patients may lack cultural sensitivity. Further compounding the issue is a deep-seated distrust of the medical research community, which has a long history in the United States of unethical treatment, abuse and exploitation of African American patients.

Commodore-Mensah said those challenges could be overcome by doing a better job of communicating the benefit of research studies and making sure trusted individuals, such as faith and community leaders, are the ones delivering those messages.

"We also need to make sure the research team reflects the population we are studying," she said.

Blacks and Heart Valve Disease

African Americans have the highest rate of heart valve disease in the U.S. The danger of heart valve disease is that it's condition is too often undiagnosed and untreated. Blacks are less likely to undergo surgery to repair heart valves due to not being evaluated for surgery, declining to pursue surgical repair, or being unaware of it.  

According to a study commissioned by the Alliance for Aging Research, the public at large has an insufficient awareness of heart valve disease, but this is acutely true for minority populations. The nationwide survey conducted for the study, only 18 percent of African-Americans were familiar with heart valve disease. This is a particularly dangerous finding, given the high propensity of Black Americans to be afflicted with cardiovascular illnesses and congestive heart failure.

What is Heart Valve Disease?

Valvular heart disease is characterized by damage to or a defect in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary.

The mitral and tricuspid valves control the flow of blood between the atria and the ventricles (the upper and lower chambers of the heart). The pulmonary valve controls the flow of blood from the heart to the lungs, and the aortic valve governs blood flow between the heart and the aorta, and thereby the blood vessels to the rest of the body.

The mitral and aortic valves are the ones most frequently affected by valvular heart disease. Normally functioning valves ensure that blood flows with proper force in the proper direction at the proper time. In valvular heart disease, the valves become too narrow and hardened (stenotic) to open fully, or are unable to close completely (incompetent).

A stenotic (narrowed, tight) valve forces blood to back up in the adjacent heart chamber, while an incompetent (leaky) valve allows blood to leak back into the chamber it previously exited. To compensate for poor pumping action, the heart muscle enlarges and thickens, thereby losing elasticity and efficiency. In addition, in some cases, blood pooling in the chambers of the heart has a greater tendency to clot, increasing the risk of stroke or pulmonary embolism.

The severity of valvular heart disease varies. In mild cases, there may be no symptoms, while in advanced cases, valvular heart disease may lead to congestive heart failure and other complications. Treatment depends upon the extent of the disease.

What Symptoms Will I Get if I Have Heart Valve Disease?

Heart valve disease symptoms can occur suddenly, depending upon how quickly the disease develops. If it advances slowly, then your heart may adjust and you may not notice the onset of any symptoms easily. 

Additionally, the severity of the symptoms does not necessarily correlate to the severity of the valve disease. That is, you could have no symptoms at all, but have severe valve disease. Conversely, severe symptoms could arise from even a small valve leak.

Many of the symptoms are similar to those associated with congestive heart failure, such as shortness of breath and wheezing after limited physical exertion and swelling of the feet, ankles, hands or abdomen (oedema). Other symptoms include:

*Palpitations, chest pain (may be mild).

*Fatigue.

*Dizziness or fainting (with aortic stenosis).

*Fever (with bacterial endocarditis, infection over a damaged valve).

*Rapid weight gain due to fluid accumulation

What Causes my Heart Valve to be Damaged or Diseased?

There are many different types of valve disease; some types can be present at birth (congenital), while others may be acquired later in life; the following are causes for damaged heart valves:

*Heart valve tissue may degenerate with age.

*Rheumatic fever may cause valvular heart disease.

*Bacterial endocarditis; an infection of the inner lining of the heart muscle and heart valves (endocardium), is a cause of valvular heart disease.

*High blood pressure and atherosclerosis may damage the aortic valve.

*A heart attack may damage the muscles that control the heart valves.

*Other disorders such as carcinoid tumors, rheumatoid arthritis, systemic lupus erythematosus, or syphilis may damage one or more heart valves.

*Methysergide, a medication used to treat migraine headaches, and some diet drugs may promote valvular heart disease.

*Radiation therapy (used to treat cancer) may be associated with valvular heart disease.

Is There Anything I Can do to Prevent Heart Valve Disease?

Get prompt treatment for a sore throat that lasts longer than 48 hours, especially if accompanied by a fever. Timely administration of antibiotics may prevent the development of rheumatic fever which can cause valvular heart disease.

A heart-healthy lifestyle is also advised to reduce the risks of high blood pressure, atherosclerosis and heart attack. Don’t smoke and consume no more than 5 alcoholic beverages per week.

Eat a healthy, balanced diet low in salt and fat, exercise regularly and lose weight if you are overweight. Adhere to a prescribed treatment program for other forms of heart disease. If you are diabetic, maintain careful control of your blood sugar.

How is Heart Valve Disease Diagnosed?

As part of your heart valve disease diagnosis you will undergo one or more of the following tests:

*An electrocardiogram, also called an ECG or EKG, to measure the electrical activity of the heart, regularity of heartbeats, thickening of the heart muscle (hypertrophy) and heart-muscle damage from coronary artery disease.

*Stress testing, also known as treadmill tests, measure blood pressure, heart rate, ECG changes and breathing rates during exercise. During this test, the heart’s electrical activity is monitored through small metal sensors applied to your skin while you exercise on a treadmill.

*Chest X-rays

*Echocardiogram to evaluate heart function. During this test, sound waves bounced off the heart are recorded and translated into images. The pictures can reveal abnormal heart size, shape and movement. Echocardiography also can be used to calculate the ejection fraction, or volume of blood pumped out to the body when the heart contracts.

*Cardiac catheterization, which is the threading of a catheter into the heart chambers to measure pressure irregularities across the valves (to detect stenosis) or to observe backflow of an injected dye on an X-ray (to detect incompetence).

What Treatment is Available for Heart Valve Disease?

The following provides an overview of the treatment options for valvular heart disease:

*Don’t smoke; follow prevention tips for a heart-healthy lifestyle. Avoid excessive alcohol consumption, excessive salt intake and diet pills—all of which may raise blood pressure.

*If you are not very limited by the valve disease and if the valve on assessment does not appear severely diseased, I might suggest a “watch and wait” policy particularly with mild or asymptomatic cases.

*A course of antibiotics is prescribed prior to surgery or dental work for those with valvular heart disease, to prevent bacterial endocarditis.

*Long-term antibiotic therapy is recommended to prevent a recurrence of streptococcal infection in those who have had rheumatic fever.

*Antithrombotic (clot-preventing) medications such as aspirin and or clopidogrel may be prescribed for those with valvular heart disease who have experienced unexplained transient ischemic attacks, also known as TIAs (mini-stroke).

*More potent anticoagulants, such as warfarin, may be prescribed for those who have atrial fibrillation (a common complication of mitral valve disease) or who continue to experience TIAs despite initial treatment. Long-term administration of anticoagulants may be necessary following valve replacement surgery because prosthetic valves are associated with a higher risk of blood clots.

*Balloon dilatation (a surgical technique involving insertion into a blood vessel of a small balloon that is led via catheter to the narrowed site and then inflated) may be done to widen a stenotic valve.

*Valve surgery to repair or replace a damaged valve may be necessary.

*Replacement valves may be artificial (prosthetic valves) or made from animal tissue (bioprosthetic valves). The type of replacement valve selected depends on your age, condition and the specific valve affected.

Is There Any Alternative to Open Heart Surgery?

A number of per-cutaneous minimally-invasive (key hole) cardiac interventions are becoming increasingly popular and can give as good results as the open surgery which include:

*TAVR (Trans-catheter Aortic Valve Replacement)- to treat a tightly narrowed aortic valve (Aortic Stenosis)

*MITRACLIP procedure to treat a leaky Mitral Valve

*Baloon Valvotomy to expand tight (stenotic) mitral or aortic valves

Black people Get Fewer Heart Valve Replacements, But Inequity Gap is Narrowing

 By American Heart Association News (8/11/20)

Black people with severely malfunctioning heart valves are less likely than their white peers to receive lifesaving valve replacements, according to a new study.

The study, published Tuesday in the Journal of the American Heart Association, looked at the treatment rates by race for aortic valve stenosis, a condition when the valve doesn't open and close properly and may leak blood.

Recent valve replacement technology has increased the life expectancy for people with the worst cases. If left untreated, half of patients with severe aortic valve stenosis die within two years, the study said. With treatment, however, they can get relief from symptoms and return to "a normal life trajectory."

Researchers examined a decade of electronic health records for 32,853 people with severe aortic valve stenosis and found valve replacement rates were low regardless of race: Only 36% of patients got the procedure within a year of their diagnosis.

"The big elephant in the room is that two-thirds of patients who ought to be treated are not getting treated. It's still a major problem," said the study's lead author, Dr. J. Matthew Brennan.

Even after adjusting for socioeconomic factors, researchers found Black people with the condition were less likely to undergo valve replacement than white people – 22.9% versus 31% – despite similar one-year survival rates for both races.

The racial gap narrowed slightly – 29.5% versus 35.2%, respectively – during 2015-2016 because more Black people received transcatheter aortic valve replacements. Also called TAVR, it is a newer, minimally invasive procedure whose use has dramatically increased in recent years for patients with severe stenosis. With TAVR, doctors insert an artificial valve into the diseased valve using a less invasive procedure, with potentially less complications and a quicker recovery.

Despite the progress in closing the gap on racial disparities, obstacles remain for Black people with aortic valve stenosis, according to the study.

"I think we're only seeing the tip of this iceberg," said Brennan, an interventional cardiologist at Duke University Medical Center. "We only looked at patients who'd been diagnosed and there are a lot of folks who don't get medical care, especially in minority populations."

Brennan said he'd like to see future studies explore why racial differences in treatment persist and how doctors can detect the disease quicker.

"People need to understand this is a deadly disease, treatment is critical, and if people are treated, they really do well," he said.

Dr. Mohamad Adnan Alkhouli, who was not involved in the research, said past studies had found racial differences in aortic valve replacement rates but didn't look specifically at people with confirmed cases of severe stenosis.

"This study is very important because for the first time it documents a clear racial disparity among those who are already diagnosed. It gets to the bottom of the disparity so we can start to fix it," said Alkhouli, a cardiologist and professor at Mayo Clinic School of Medicine in Rochester, Minnesota.

He called for heart and medical organizations "to get together and come up with a final plan for action," and for future studies to address why the disparities exist.

"The big question where is the gap? Is it in access to care, provision of care, or both? Do socioeconomic and cultural differences also play a role?It's a big puzzle, but each new study will add a bit of knowledge to solve the puzzle."