Women, especially Black women with chronic obstructive pulmonary disease (COPD), are at high risk for not receiving recommended statin treatment for the prevention of cardiovascular disease, according to a recent study conducted by physicians at NewYork-Presbyterian/
Individuals with COPD often have co-occurring cardiovascular disease, putting them at increased risk for emergency visits, hospitalizations, and even death, says Jamuna K. Krishnan, MD, MBA, MS, a pulmonary and critical care specialist at NewYork-Presbyterian/
In the study, Dr. Krishnan and her colleagues found that Black women who had COPD had the lowest proportion of statin treatment among patients with an indication– at 49.6% – compared with all other race and sex groups.
“As a pulmonologist and even when I was a medical resident, I would see that a lot of my patients with COPD often have pretty bad heart disease,” she says. “As a medical community, we struggle with taking care of both of those conditions well because there’s a lot of overlap in the symptoms, the patients are really sick, and they see a lot of different doctors.”
These issues are exacerbated among Black women. In prior research published in the Annals of the American Thoracic Society, Dr. Krishnan found that Black women with COPD have a 44% higher risk of cardiovascular-related mortality than White women with COPD.
“The question is, what are we doing to prevent heart disease in Black women with COPD?” says Dr. Krishnan. “Statins are an evidence-based medication, so we wanted to see, are there disparities among Black men and women with COPD in the receipt of this clearly helpful medication?”
Statins are an evidence-based medication, so we wanted to see, are there disparities among Black men and women with COPD with this clearly helpful medication?
— Dr. Jamuna K. Krishnan
The Role of Race and Sex in Cardiovascular Disease Treatment
In the current study, Dr. Krishnan and her colleagues identified race and sex differences in the receipt of guideline-recommended statin treatment for cardiovascular disease among a cohort of Medicare patients with COPD who were enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. REGARDS includes data from community-dwelling Black and White adults, and medication information from in-home pill bottle review performed by trained health professionals.
Dr. Krishnan and her colleagues also examined predisposing, enabling, and need-related factors that have the potential to influence individual use of health services. Some of the factors considered include:
- Predisposing factors: age, education, place of residence, poverty level
- Enabling factors: social isolation, poor social network
- Need factors: diagnosed hyperlipidemia, medication adherence, smoking status, depressive symptoms
Among the 1,435 patients in the analysis who were diagnosed with COPD and had an indication for statin treatment, nearly 60% received treatment. White men had the highest proportion of statin treatment (67%), while Black women had the lowest (49.6%).
Overall, 41.3% of participants had a statin indicated for primary prevention of cardiovascular disease and 56.6% required secondary prevention. Black women who had an indication for primary prevention were the least treated group in the study. However, even when Black women had a history of diagnosed cardiovascular disease, they were 18.1% less likely than White men to receive secondary prevention with a statin, the researchers found.
Many patients have both COPD and cardiovascular disease.
After adjusting for the predisposing, enabling, and need factors that influence the uptake of health care services, Dr. Krishnan found that both White women and Black women had a lower prevalence ratio for statin treatment than White men, while the gap between Black and White men was no longer statistically significant.
The finding suggests that solutions may need to come at the health system level rather than at the individual level, says Dr. Krishnan. The differences could be driven by discrimination or an under recognition of heart disease in women, for example, but further research will be needed to tease out those answers.
“To me, the takeaway is that the fix might need to be a health system intervention that takes place at multiple levels. Maybe it’s retraining or talking to doctors about proactively assessing this risk in our patients with COPD and treating it,” says Dr. Krishnan. “There’s room for improvement in how we deliver health care.”
To me, the takeaway is that the fix might need to be a health system intervention that takes place at multiple levels.
— Dr. Jamuna K. Krishnan
The message for pulmonologists is that they may need to look beyond COPD and ensure that patients are receiving evidence-based prevention for cardiovascular risk factors, especially among Black women. “If you’re Black and you’re a woman, the barriers are greater than having either of these of these individual identities,” says Dr. Krishnan. “Black women need more support in our health care system to make sure the outcomes are equitable.”
