Risk for atherosclerotic cardiovascular disease (ASCVD) shows considerable heterogeneity both in generally healthy persons and in those with known ASCVD. The foundation of preventive cardiology begins with assessing baseline ASCVD risk using global risk scores based on standard office-based measures. Persons at low risk are generally recommended for lifestyle management only and those at highest risk are recommended for both lifestyle and pharmacologic therapy. Additional "risk enhancing" factors, including both traditional risk factors and novel biomarkers and inflammatory factors can be used to further assess ASCVD risk, especially in those at borderline or intermediate risk. There are also female-specific risk enhancers, social determinants of health, and considerations for high-risk ethnic groups. Screening for subclinical atherosclerosis, especially with the use of coronary calcium screening, can further inform the treatment decision if uncertain based on the above strategies. Persons with pre-existing ASCVD also have variable risk, affected by the number of major ASCVD events, whether recurrent events have occurred recently, and the presence of other major risk factors or high-risk conditions. Current guidelines define high to very high risk ASCVD accordingly. Accurate ASCVD risk assessment is crucial for the appropriate targeting of preventive therapies to reduce ASCVD risk. Finally, the clinician-patient risk discussion focusing on lifestyle management and the risks and benefits of evidence-based pharmacologic therapies to best lower ASCVD risk is central to this process. This clinical practice statement provides the preventive cardiology specialist with guidance and tools for assessment of ASCVD risk with the goal of appropriately targeting treatment approaches for prevention of ASCVD events. 

https://doi.org/10.1016/j.ajpc.2022.100335

Atherosclerotic cardiovascular disease risk assessment: An American Society for Preventive Cardiology clinical practice statement

Black adults experience a disproportionately higher burden of cardiovascular risk factors and disease in comparison with White adults in the United States. Less is known about how sex-based disparities in cardiovascular mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation.We used CDC WONDER (Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research) to identify Black and White adults age ≥25 years in the United States from 1999 to 2019. We calculated annual age-adjusted cardiovascular mortality rates (per 100 000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural versus urban residence, and degree of neighborhood segregation.From 1999 to 2019, age-adjusted mortality rates declined overall for both Black and White adults. There was a decline in age-adjusted cardiovascular mortality among Black (602.1 to 351.8 per 100 000 population) and White women (447.0 to 267.5), and the absolute rate difference (ARD) between these groups decreased over time (1999: ARD, 155.1 [95% CI, 149.9-160.3]; 2019: ARD, 84.3 [95% CI, 81.2-87.4]). These patterns were similar for Black (824.1 to 526.3 per 100 000) and White men (637.5 to 396.0; 1999: ARD, 186.6 [95% CI, 178.6-194.6]; 2019: ARD, 130.3 [95% CI, 125.6-135.0]). Despite this progress, cardiovascular mortality in 2019 was higher for Black women (rate ratio, 1.32 [95% CI, 1.30-1.33])- especially in the younger (age <65 years) subgroup (rate ratio, 2.28 [95% CI, 2.23-2.32])-as well as for Black men (rate ratio, 1.33 [95% CI, 1.32-1.34]), compared with their respective White counterparts. There was regional variation in cardiovascular mortality patterns, and the Black-White gap differed across rural and urban areas. Cardiovascular mortality rates among Black women and men were consistently higher in communities with high levels of racial segregation compared with those with low to moderate levels.During the past 2 decades, age-adjusted cardiovascular mortality declined significantly for Black and White adults in the United States, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher cardiovascular mortality rates than their White counterparts. 

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.122.060199

Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019

Background: Black adults experience a disproportionately higher burden of cardiovascular risk factors and disease in comparison with White adults in the United States. Less is known about how sex-based disparities in cardiovascular mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation. Methods: We used CDC WONDER (Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research) to identify Black and White adults age ≥25 years in the United States from 1999 to 2019. We calculated annual age-adjusted cardiovascular mortality rates (per 100 000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural versus urban residence, and degree of neighborhood segregation. Results: From 1999 to 2019, age-adjusted mortality rates declined overall for both Black and White adults. There was a decline in age-adjusted cardiovascular mortality among Black (602.1 to 351.8 per 100 000 population) and White women (447.0 to 267.5), and the absolute rate difference (ARD) between these groups decreased over time (1999: ARD, 155.1 [95% CI, 149.9–160.3]; 2019: ARD, 84.3 [95% CI, 81.2–87.4]). These patterns were similar for Black (824.1 to 526.3 per 100 000) and White men (637.5 to 396.0; 1999: ARD, 186.6 [95% CI, 178.6–194.6]; 2019: ARD, 130.3 [95% CI, 125.6–135.0]). Despite this progress, cardiovascular mortality in 2019 was higher for Black women (rate ratio, 1.32 [95% CI, 1.30–1.33])— especially in the younger (age <65 years) subgroup (rate ratio, 2.28 [95% CI, 2.23–2.32])—as well as for Black men (rate ratio, 1.33 [95% CI, 1.32–1.34]), compared with their respective White counterparts. There was regional variation in cardiovascular mortality patterns, and the Black-White gap differed across rural and urban areas. Cardiovascular mortality rates among Black women and men were consistently higher in communities with high levels of racial segregation compared with those with low to moderate levels. Conclusions: During the past 2 decades, age-adjusted cardiovascular mortality declined significantly for Black and White adults in the United States, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher cardiovascular mortality rates than their White counterparts.

HomeCirculationVol. 145, No. 7Shining a Light on the Superwoman Schema and Maternal Health Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessArticle CommentaryPDF/EPUBShining a Light on the Superwoman Schema and Maternal Health Rachel M. Bond, Annette Ansong and Michelle A. Albert Rachel M. BondRachel M. Bond https://orcid.org/0000-0001-7300-8028 Dignity Health, Arizona, Chandler (R.M.B.). Division of Cardiology, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE (R.M.B.). Search for more papers by this author , Annette AnsongAnnette Ansong Division of Cardiology, Children’s National Hospital, Washington, DC (A.A.). Search for more papers by this author and Michelle A. AlbertMichelle A. Albert Correspondence to: Michelle A. Albert, MD, MPH, University of California at San Francisco (UCSF), Cardiology Division, 505 Parnassus Ave, San Francisco, CA 94143. Email E-mail Address: [email protected] Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine (M.A.A.). Search for more papers by this author Originally published14 Feb 2022https://doi.org/10.1161/CIRCULATIONAHA.121.058905Circulation. 2022;145:507–509A wise woman wishes to be no one’s enemy. A wise woman wishes to be no one’s victim.—Maya AngelouThe maternal mortality crisis is an example of how social determinants of health serve as an undercurrent for acute and chronic cardiovascular disease risk in women, especially Black women, who are disproportionately affected. In the United States, pregnancy-related mortality is at least 3 times higher among Black women compared with White women.1 These maternal statistics are independent of socioeconomic status, with Black women across the education, income, and wealth spectrum experiencing higher pregnancy risks. Risk is further amplified by additional psychosocial stressors experienced by Black women, such as systematic racism and misogyny. Indeed, some data indicate that Black women more frequently report cumulative psychosocial stressors and have lower ideal cardiovascular health than White, Asian, and Hispanic women.2 Moreover, among Black female health professionals, ≈13% of ideal cardiovascular health was mediated by cumulative psychosocial stress.2 Likewise, psychosocial stress among Black women is linked to incident cardiovascular outcomes.3 In response to the longstanding Black maternal health crisis, the Association of Black Cardiologists convened a Black Maternal Heart Health Roundtable in June 2020 with a subsequent publication that outlined unifying solutions to improve health outcomes for Black women across the age continuum through leveraging multidisciplinary collaborations with obstetrics, maternal fetal medicine, cardiology, primary care clinicians, midwives, doulas, and pediatricians.4 In addition, advocacy efforts at the local and federal levels are essential to diversify the medical workforce through authentic identification and removal of structural barriers for entry and success within medicine, extension of insurance coverage, and provision of paid maternal leave.Although cardiovascular disease risk factors such as hypertension and obesity contribute to adverse pregnancy outcomes among Black women, a less discussed factor is the impact of psychosocial stress, particularly through the conceptual framework of the “superwoman schema.”5 The superwoman schema, characterized by Woods-Giscombé5 and incorporated into the “biology of adversity” framework (Figure), captures as stressors the history of stereotyping, oppression, disappointment, and abuse, along with spiritual values and foremother influences, among Black women interfacing with the neurobiological axis in a manner that results in upregulation of the sympathetic nervous system and hypothalamic axis and inflammatory dysregulation, resulting in untoward maternal and nonmaternal health outcomes. Subscale components of manifesting strength, determination to succeed, helping others over self, and vulnerability resistance potentially interface with other behaviors and epigenetic and genetic factors. Black women are more likely breadwinners and caregivers of children and elderly relatives and experience bias more frequently than women of other racial and ethnic groups, oftentimes against a backdrop of less access to contemporary and intergenerational wealth. Despite these challenges, Black women are expected to be “strong” while ignoring their own health and wellness. In addition, societal structural racism and implicit bias in health care lead caregivers to dismiss concerns raised by women, especially Black women and other women of color.Download figureDownload PowerPointFigure. Biology of the superwoman schema. Adversity-superwoman schema. HPA indicates hypothalamic-pituitary-adrenal; and SNS, sympathetic nervous system. Adapted from Woods-Giscombé.5 Copyright © 2010, Sage Publications.The thematic element of psychosocial stress among Black women, compounded by pregnancy as a stress test, ushers in a tsunami of poor cardiovascular health. Although conditions such as preterm delivery, preeclampsia, and eclampsia have well-known associations with heightened cardiovascular disease risk, relatively less attention is paid to psychosocial stressors relating to job, community, financial status, desirability, family, and associated inherent stress related to racism that affect maternal and cardiovascular outcomes of Black women regardless of socioeconomic status. The COVID-19 syndemic for people of color intensifies the urgency of their maternal health crisis; Black and Hispanic pregnant women have encountered more negative prenatal and postnatal experiences than White women. Prevalent clinical comorbidities and socioeconomic factors contribute to these findings. These observations underscore the importance of eliminating vaccine hesitancy among pregnant people, especially among those from racially and ethnically diverse groups among whom a lack of trust, driven by psychosocial experiences, remains prevalent.Although psychosocial factors and other social determinants of health often result in a fait accompli attitude among cardiologists and other physicians, this need not be the case. For health care providers to be effective in tackling the maternal health crisis for diverse racial and ethnic people, especially Black women, first and foremost, we need to carefully listen to and respond effectively to our patients’ stressors. In addition to addressing traditional cardiovascular disease risk factors such as hypertension, careful consideration must be given to critical inflection periods during the reproductive life cycle of all women in conjunction with lost opportunities to address social determinants of health. A multidisciplinary team approach that includes collaboration with subspecialities on care pathways from preconception through antepartum, during the critical postpartum year or the fourth trimester and beyond is imperative. Additionally, policy creation, reduction in disparities and preventable morbidity and mortality, education of pregnant people and their support networks as well as their caregivers about the effect of psychosocial factors on their health outcomes is crucial. Inclusive efforts must also involve the LGBTQIA+ community and other vulnerable populations. However, education is only the beginning. Emerging fields such cardio-obstetrics and other efforts seeking to address maternal health, especially for Black people, must include opportunities to address holistic concerns while leveraging culturally appropriate and congruent care delivered by clinicians, social volunteers, and community health navigators within and outside of health care organizations.On the research front, scientists need to be prescriptive about implementation work that links risk factor (such as blood pressure and obesity) control efforts with data collection and interventions pertaining to social determinants of health in both standardizedand qualitative formats. For example, the American Heart Association has boldly committed at least $100 million to address health equity and structural racism and to fund a health equity research network focused on maternal and infant mortality. Last, diverse teams comprising individuals such as physicians of color who are trusted partners and have the lived experiences of those individuals disproportionately affected by the maternal health crisis are critical for eliminating maternal health inequities and disparities to improve maternal health for all.Article InformationSources of FundingNone.Disclosures Dr Albert is president-elect of the American Heart Association and president of the American Association of Black Cardiologists. Drs Bond and Ansong report no conflicts.FootnotesCirculation is available at www.ahajournals.org/journal/circThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.This article is part of the Science Goes Red™ collection. Science Goes Red™ is an initiative of Go Red for Women®, the American Heart Association’s global movement to end heart disease and stroke in women.The podcast and transcript are available as Supplemental Material at https://www.ahajournals.org/doi/suppl/10.1161/CIRCULATIONAHA.121.058905.For Sources of Funding and Disclosures, see page 509.Correspondence to: Michelle A. Albert, MD, MPH, University of California at San Francisco (UCSF), Cardiology Division, 505 Parnassus Ave, San Francisco, CA 94143. Email michelle.[email protected]eduReferences1. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013.Obstet Gynecol. 2017; 10:66–67. doi: 10.1097/acog/000000000002114Google Scholar2. Burroughs Peña MS, Mbassa RS, Slopen NB, Williams DR, Buring JE, Albert MA. Cumulative psychosocial stress and ideal cardiovascular health in older women.Circulation. 2019; 139:2012–2021. doi: 10.1161/CIRCULATIONAHA.118.033915LinkGoogle Scholar3. Felix AS, Lehman A, Nolan TS, Sealy-Jefferson S, Breathett K, Hood DB, Addison D, Anderson CM, Cené CW, Warren BJ, et al. Stress, resilience, and cardiovascular disease risk among Black women.Circ Cardiovasc Qual Outcomes. 2019; 12:e005284. doi: 10.1161/CIRCOUTCOMES.118.005284LinkGoogle Scholar4. Bond RM, Gaither K, Nasser SA, Albert MA, Ferdinand KC, Njoroge JN, Parapid B, Hayes SN, Pegus C, Sogade B, et al; Association of Black Cardiologists.Working agenda for Black mothers: a position paper from the Association of Black Cardiologists on solutions to improving Black maternal health.Circ Cardiovasc Qual Outcomes. 2021; 14:e007643. doi: 10.1161/CIRCOUTCOMES.120.007643LinkGoogle Scholar5. Woods-Giscombé CL. Superwoman schema: African American women’s views on stress, strength, and health.Qual Health Res. 2010; 20:668–683. doi: 10.1177/1049732310361892CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByKhan S, Brewer L, Canobbio M, Cipolla M, Grobman W, Lewey J, Michos E, Miller E, Perak A, Wei G and Gooding H (2023) Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association, Circulation, 147:7, (e76-e91), Online publication date: 14-Feb-2023. Goodman R, Lamberg M, Wilcox K, Minhas A, Bond R, Yang E, Shahandeh N and Brown S (2022) Social Media and Cardiovascular Health: Implications for Women, Current Atherosclerosis Reports, 10.1007/s11883-022-01069-9, 24:12, (901-913), Online publication date: 1-Dec-2022. Bond R, Phillips K, Ivy K, Ogueri V, Parapid B, Miller S and Ansong A (2022) Cardiovascular Health of Black Women Before, During, and After Pregnancy: A Call to Action and Implications for Prevention, Current Cardiovascular Risk Reports, 10.1007/s12170-022-00703-0, 16:11, (171-180), Online publication date: 1-Oct-2022. Brownlow B (2022) How Racism “Gets Under the Skin”: An Examination of the Physical- and Mental-Health Costs of Culturally Compelled Coping, Perspectives on Psychological Science, 10.1177/17456916221113762, (174569162211137) Tamirisa K, Dye C, Bond R, Hollier L, Marinescu K, Vaseghi M, Russo A, Gulati M and Volgman A (2022) Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration, Journal of Cardiovascular Development and Disease, 10.3390/jcdd9070199, 9:7, (199) February 15, 2022Vol 145, Issue 7 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.058905PMID: 35157523 Originally publishedFebruary 14, 2022 Keywordsstresssocial factorsracematernalethnicitycardiovascularPDF download Advertisement SubjectsMental HealthPregnancyRace and EthnicityVascular DiseaseWomen, Sex, and Gender 

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.121.058905

Shining a Light on the Superwoman Schema and Maternal Health

Pregnancy is associated with significant hemodynamic changes, making it a potentially high-risk period for women with underlying cardiovascular disease. Echocardiography remains the preferred modality for diagnosis and monitoring of pregnant women with cardiovascular disease as it is widely available and does not require radiation. This paper reviews the role of echocardiography along the continuum of pregnancy in at-risk patients, with a focus on key cardiac disease states in pregnancy. In the preconception stage, risk stratification scores such as CARPREG II, ZAHARA and the modified WHO remain central to counseling and planning. As such, echocardiography serves an important role in assessing the severity of pre-existing structural disease. Among women with pre-existing cardiovascular disease who become pregnant—as well as those who develop cardiovascular symptoms during pregnancy—echocardiography is a key imaging tool for assessment of hemodynamic and structural changes and is recommended as the first-line imaging modality when appropriate by both the American College of Obstetricians and Gynecologists (ACOG) and the Food and Drug Administration (FDA). However, routine screening intervals during pregnancy for various cardiac lesions are not well defined, resulting in clinical heterogeneity in care. Echocardiography is the imaging modality of choice for defining, risk stratifying, and monitoring cardiovascular changes throughout pregnancy. Once identified, at-risk patients should receive careful individual counseling and follow-up with a multidisciplinary team. Echocardiography serves as a widely available tool for serial monitoring of pregnant women with cardiovascular disease throughout pregnancy and the postpartum period.

/pdf/echocardiography-for-the-pregnant-heart-24z62l5qh4.pdf

Echocardiography for the Pregnant Heart.

Following decades of decline, maternal mortality began to rise in the United States around 1990—a significant departure from the world’s other affluent countries By 2018, the same could be seen wi

Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health.

SARS-CoV-2, which causes COVID-19, created a pandemic that not only overwhelmed the world in December 2019, but also challenged humanity in every way. While a significant portion of the global population remained in a standstill, waiting for an end and adapting to limits of all sorts, including working from home, a new workforce category emerged: the “frontline” workers. Doctors, nurses, and all allied professions employed by the healthcare system were joined by a long line of diverse service providers. The [...]

/pdf/covid-19-an-insult-to-injury-on-equity-3pxnas6p8p.pdf

Biljana Parapid

Papers

Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health.

COVID-19: An Insult to Injury on Equity