Recommended Management of Cardiovascular Health in American Indians and Alaska Natives

A scientific statement from the American Heart Association (AHA) published in Circulation outlines considerations for cardiovascular health in American Indian and Alaska Native populations, including evaluation of risk factors and management options specific to these populations.

Cardiovascular disease (CVD), including coronary heart disease (CHD), stroke, heart failure, and arrhythmias, are very common among American Indians and Alaska Natives. In the AHA’s scientific statement, risk factors for CVD were divided into 3 categories: clinical, behavioral, and demographic and genetic risk factors.

Clinical risk factors include age, sex, diabetes, low-density lipoprotein cholesterol, hypertension, smoking, and albuminuria. In American Indians, diabetes is 3 times more common than in whites and is the most important risk factor for CHD. Renal disease is also common in Native Americans due to the high rates of diabetes and was previously found to be associated with cardiovascular morbidity, including CHD, and overall mortality. Additional clinical risk factors include obesity, which is increasing rapidly in American Indians, and inflammatory processes. According to some research, C-reactive protein levels may have especially important prognostic value for CVD in these populations.

Potential relevant behavioral risk factors for CVD include cigarette smoking, which is more common among American Indians and Alaska Natives than in other US adults, as well as physical inactivity and heavy alcohol use.

Risk evaluation for CVD in American Indians and Alaska Natives should also incorporate demographic factors including age and sex and genetic risk. It is important to note that American Indians and Alaska Natives develop CVD at earlier ages than white individuals and that men have higher rates of CVD than women. Furthermore, cardiovascular mortality rates are higher in Alaska Natives and American Indians compared with white patients. Data on the role of genetics in CVD among these populations are still limited and more studies are needed, but some research suggests that 20% to 50% of the CVD risk factor phenotype is contributed to genetics.

Social factors may also contribute to increased cardiovascular morbidity and mortality in American Indians and Alaska Natives. Low socioeconomic status, exposure to psychosocial stressors, low educational attainment, and poverty are all more common in these populations and can significantly increase the risk for cardiovascular complications. Additional potential factors that cause health inequities include lack of health insurance, limited health services, and disproportionately high exposure to environmental chemicals.

Community-based programs may assist in controlling cardiovascular risk factors. These include the Diabetes Prevention Program and Healthy Heart, which are aimed at improving risk factors, as well as the Native-CHART project (Native-Controlling Hypertension and Risk Through Technology), which focuses on improving blood pressure control and additional risk factors for stroke among American Indians, Alaska Natives, and Asia-Pacific Islanders with hypertension. In addition, the Centers for Disease Control and Prevention developed the REACH program (Racial and Ethnic Approaches to Community Health) to improve adherence to medical treatment for hypertension among American Indians.

Community-talking circles may be useful settings to educate and empower American Indians and Alaska Natives to manage CVD risk and diabetes. Shared decision making is an important aspect of care for CVD in these populations and strategies to improve cultural competence and reduce discrimination and bias among healthcare professionals are important. These include counteracting stereotypes and considering the perspective of the individual patient.

“Prevention and treatment of CVD in American Indians and Alaska Natives should focus on control of risk factors and community-based interventions that address social determinants of health, particularly among individuals with diabetes mellitus,” concluded the authors of the AHA scientific statement.

Disclosure: One study author declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures

Reference

Breathett K, Sims M, Gross M, et al. Cardiovascular health in American Indians and Alaska Natives: a scientific statement from the American Heart Association [published online May 28, 2020]. Circulation. doi:10.1161/CIR.0000000000000773