Keith C. Ferdinand, MD: Heart Failure Disparity in the US

How disparities in cardiovascular disease and its comorbidities most commonly present, unfortunately, is in patient mortality. Black patients have been notably burdened by a greater rate of cardiovascular mortality risk for years now, and are continuously under-represented in major clinical trials.

In an interview with MD Magazine®, Keith C. Ferdinand, MD, Gerald S. Berenson Endowed Chair in Preventive Cardiology and professor of Medicine at Tulane University School of Medicine, explained the burden of race disparity in cardiovascular disease, and whether potential therapies may help reduce it.

MD Mag: What is the disparity of heart failure among patient subgroups? How can it be lessened?

Ferdinand: If you look at the rates of cardiovascular disease, it's starting to plateau. So, after it decreased for several decades, it started to plateau or slow in its decline, and that's been seen both in white and black patients in the United States.

Nevertheless, there still is a white-black death gap, whereas in the black patients you have higher degrees of cardiovascular mortality including heart attacks, heart failure, chronic kidney disease, end-stage renal disease, and stroke, compared to the white patients.

Those disparities are part of the fabric of the healthcare delivery system in the United States that must be addressed. We need to make sure that patients have good access to health care, health insurance, have an identifiable source of primary care, have appropriate referral to specialists and on a one-to-one basis, we need to address our patients to understand their disease process and why it's necessary to take medicines or have certain diagnostic tests.

When we talk to our patients, we shouldn't try to show how smart we are, using very technical language, but use literacy appropriate, culturally appropriate language, that the patient can understand his or her condition—and why it's important to change lifestyle and take medications when needed.

MD Mag: Could SGLT2 inhibitors play a role in lessening the disparity of heart failure burden among patients?

Ferdinand: When we look at cardiovascular conditions, including heart attacks, strokes, chronic kidney disease, end-stage renal disease—they're much higher in the African-American population.

Unfortunately, many of our landmark trials have underrepresented American blacks, while they're disproportionately affected by these conditions. There are only about 2-3 or 4% of those large, randomized trials.

That being said, it makes sense for patients who tend to have salt-sensitive, low renin hypertension. SGLT2 inhibitors—which appear to increase the secretion of excess sodium, excess water, to make the endothelial function improve—may be beneficial in that population.

If you look just at the Medicare registry—and all taxpayers pay for persons who have end-stage renal disease because Medicare will ensure their care on dialysis at a tune of anywhere from $95 to $120 thousand a year—whereas African Americans are only 12% to 13% of the population, there are over 35% of the persons who are on dialysis.

Therefore we can save cost to the population, we can save death and disability, by treating patients more ambitiously. I think the SGLT2 inhibitors, which have been shown now to protect against kidney disease, heart failure, and overall cardiovascular disease —especially because they have an ability to excrete excess sodium and water—may be really beneficial in the African-American population.

In a study that I did that was published in circulation this year, we showed robust lowering of blood pressure in self-identified African Americans. Perhaps in the future we can do a better job in cardiovascular outcomes trials to make sure that they're reflective of a heterogeneous population that we have here in the United States. That being said, at this point, I think SGLT inhibitors as part of the cocktail of lowering cardiovascular risk, should be beneficial for African Americans.