The complexity of cardiovascular disease disparities has been vetted carefully in the pages of JAMA Cardiology. The requirement for careful ascertainment of race/ethnicity designations; the need to fully adjust differences based on clinical factors, socioeconomic characteristics, and social determinants of health; and the hope for genomics and eventually precision medicine to obviate the need for racial categorization have all been emphasized. Yet the investigators in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II) trial1 remind us that the task is not complete. We must be relentless in our focus to further narrow and ultimately eliminate disease disparities as a function of race/ethnicity. Differences as a function of ethnicity (self-identified Hispanic ethnicity) were less apparent, but much more evident differences as a function of black race were recalcitrant. The current data demonstrate that black individuals were 25% less likely to receive oral anticoagulation as prompted by appropriate guidelines for stroke prophylaxis and nearly 40% less likely to receive direct oral anticoagulants.1 This difference was evident after adjusting for clinical variables and then narrowed somewhat after further adjustment for socioeconomic variables but nevertheless remained—especially with regards to use of direct oral anticoagulants. One can dismiss access to care as a putative additional explanation, as the design of the ORBIT-AF II registry included leading arrhythmia centers with nearly idealized patient cohorts.1 It is plausible that certain patient-level factors, eg, patient preference and shared decision making, determined these differences. And it is indeed important to adopt the view of Cooper et al2 that “race captures a lifelong social experience,” and a full accounting of the effect of race is confounded by both measured and unmeasurable variables.
Yancy CW. Cardiovascular Disease Disparities: The Gap Remains. JAMA Cardiol. 2018;3(12):1183. doi:https://doi.org/10.1001/jamacardio.2018.4040
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