January/February 2024

Statins: Reducing Racial Disparities
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 17 No. 1 P. 14

Adequate statin prescriptions for racial minorities could help close the care gap.

Heart disease is the leading cause of death in the United States and around the world.1 Statins are a first-line preventive therapy for patients at risk of heart disease and a first-line secondary treatment for patients who already have heart disease.2,3

However, there are significant racial disparities in the prescription of statins for both primary and secondary treatment. There are also racial disparities in long-term medication adherence. Reducing these racial disparities has significant potential to reduce the burden of heart disease in the United States and to improve the lives of at-risk patients.

“[Statins] are highly effective in preventing complications of atherosclerotic cardiovascular disease, such as heart attacks and strokes, and they have been recommended by major clinical guidelines for decades,” says Ravy K. Vajravelu, MD, MSCE, an assistant professor of medicine in the division of gastroenterology, hepatology and nutrition at the University of Pittsburgh. “Ensuring that all our patients who are recommended to receive statins actually receive them is paramount for the overall health and health equity of the United States.”

Racial Disparities in Heart Disease Risk and Mortality
Although cardiovascular disease is the leading cause of death in the United States among all major racial groups, some racial and ethnic groups are at much higher risk of getting the disease—and dying from it—than others.

The rate of heart disease is highest among non-Hispanic white Americans. About 11.5% of non-Hispanic whites have heart disease, compared with just 9.5% of Blacks, 7.4% of Hispanics, and 6% of Asians.4

But although white Americans have the highest rate of heart disease diagnosis, they’re less likely to die of the disease than are their Black counterparts. The mortality rate for cardiovascular disease among white adults is only 180 out of 100,000, compared with 226 for Black adults.5 (The cardiovascular mortality rate for other racial/ethnic groups is lower: 155 for American Indians/Alaskan Natives, 119 for Hispanics, and 85.5 for Asians).

There are significant disparities not just between racial groups but also within various racial subgroups. In particular, Asian Americans have the lowest rate of heart disease and the lowest heart disease mortality of all major racial groups, but this fact obscures the significant variation between Asians of different heritages.

“The risk for South Asians is much higher than for East Asians,” says Dinesh Kalra, MD, a professor of medicine and chief of the division of cardiovascular medicine at the University of Louisville School of Medicine.6 One study of heart disease mortality among Asians found mortality among Indian Americans to be 147.15 per 100,000, compared with 97.21 per 100,000 among Vietnamese Americans. The mortality rates for Chinese, Filipino, Japanese, and Korean Americans fall somewhere in between.7

Racial Disparities in Statin Prescription and Adherence
What explains the disparities in heart disease mortality? One contributor may be differences in the prescription of and adherence to statin therapy. This treatment is strongly associated with a reduction in cardiovascular disease mortality,8 but some racial groups are much more likely than others to receive a statin prescription and to take the medication as prescribed.

Last year, a large study published in JAMA Cardiology found that Black and Hispanic participants were much less likely to be taking statin therapy for primary prevention of heart disease than were white participants with the same level of risk.9 In this study, which was based on data from the National Health and Nutrition Examination Survey (NHANES) for the years 2013 to 2020, the rate of statin therapy was 28% among eligible whites compared with just 20% of eligible Blacks and 15% of eligible Hispanics. Statin use among Asian participants was comparable to statin use among whites.

A second study last year, published in the Annals of Internal Medicine, came to broadly similar conclusions. This study, also based on NHANES data but for slightly different years, again found that Black and Hispanic individuals were less likely to receive statin therapy than were their white counterparts.10 This study found that the discrepancies were present for both primary and secondary prevention, albeit with some nuances to the data. For primary prevention, the authors identified Black men and non-Mexican Hispanic women as being less likely to receive statin therapy compared with white males. For secondary prevention, Black men, other/multiracial men, Hispanic women, white women, and Black women were all less likely to receive statin therapy thanwere white men.

The findings of these new studies are in line with previous research that’s also demonstrated higher utilization of statins among white patients compared with Black or Hispanic patients.11-14

Not only are racial minorities less likely to receive a statin, they’re also less likely to receive a statin prescription of the proper intensity. In 2018, researchers from Duke University studied 5,689 statin-eligible patients and found that Black participants were only slightly less likely than their white counterparts to be taking a statin (71% vs 75%), but they were much less likely to receive a statin at the intensity recommended by current guidelines.15 This was true for both primary and secondary prevention. The discrepancy in treatment, in turn, contributed to higher LDL cholesterol levels among Black individuals in the study compared with whites. The study authors concluded that differences in intensity of statin therapy probably contribute to the racial differences in cardiovascular disease burden between Blacks and whites in the United States.15

Importantly, disparities in statin use could arise at various levels—at the level of screening, at the level of prescriptions, or at the level of patient adherence to prescribed treatment. None of the studies just mentioned examined at what level the disparities arise, but fortunately, other studies have touched on that question.

According to Kalra, screening is a comparatively small issue: in his experience, most patients who need a risk assessment receive it. The bigger problem is at the level of prescriptions: Research shows that a large number of patients who should be prescribed a statin based on their risk assessment never actually receive a prescription.11,16 However, disparities in prescriptions aren’t the end of the story. Other researchers also find that even among patients who receive a prescription, racial minorities are less likely to adhere to the prescribed treatment.14 Specifically, a 2013 meta-analysis found that nonwhite patients were 53% less likely than white patients to adhere to their prescribed statin treatment.17 Thus, the available research indicates that the disparities arise at the level of prescription but also at the level of patient adherence to a prescribed medication.

Reasons for Disparities
There are several factors that probably influence disparities in statin use. One of these is health insurance status. In the 2023 JAMA Cardiology study mentioned earlier, health insurance and access to routine health care were significantly associated with greater statin use across racial groups, including among Black, Hispanic, and white participants.9 This finding is consistent with that in previous literature and has led some researchers to suggest that reducing insurance copayments for statins could increase the use of statins among Black patients.18

However, health care access doesn’t explain all the disparities in statin use. Even after controlling for variables such as education, household income, and health insurance, the researchers in the JAMA Cardiology study found that statin use was still significantly higher in whites (28.6%) than in Blacks (21.1%) or Hispanics (19.9%).9

The 2023 Annals of Internal Medicine study mentioned earlier likewise found that health care access didn’t completely account for the difference in statin use across races.10 “Our study demonstrates that structural factors, such as lower income and less health access to health care, do explain a portion of the disparities in statin use, says Vajravelu, the study’s senior author. “However, because the disparities in statin use persist after accounting for the effect of structural factors, we conclude that there are also other factors beyond structural factors that contribute to statin use disparities.” Vajravelu and his team hypothesize that those could be care-process factors, including bias, stereotyping, and mistrust.

On the subject of mistrust, some research has documented racial differences in beliefs about the safety and effectiveness of statin therapy. In one study, for example, only 70% of Black participants believed statins were effective, compared with more than 74% of whites. The gap was even wider on the question of safety: 36% of Black participants believed statins were safe compared with 57% of whites who believed they were safe. The same study also identified a racial gap in patient confidence in their doctors: just 87% of Black participants, compared with about 95% of white patients, trusted their clinicians.15

Other research has found that Black patients have a less participatory relationship with their doctors than do white patients19 and that they experience poor communication quality with their doctors.20 These factors could help explain the lower levels of confidence Black patients have in both their doctors and in statin therapy.

Reducing Disparities
What can physicians do to reduce disparities?

1. Check your own prescribing patterns for racial bias.
Given that structural factors like economic status and access to health care don’t fully explain racial disparities in statin use, some researchers think bias (whether conscious or unconscious) on the part of physicians may play a role in the disparities. “We as health care providers need to examine our decision making to make sure we are not perpetuating societal biases,” Vajravelu says.

One way health care institutions can help physicians check for bias is by implementing health informatics systems that track clinicians’ adherence to evidence-based care—something that Vajravelu’s employer, the Department of Veterans Affairs, is working on. “These systems should enable health care providers to track their adherence among groups of patients to help them identify potential disparities,” Vajravelu says.

But even in the absence of a health informatics system to monitor prescribing patterns, doctors can still simply stop and ask whether they are following evidence-based recommendations for patients in their care. “Don’t discount Black and Hispanic patients,” says Ambarish Pandey, MD, an associate professor in the department of internal medicine at UT Southwestern Medical Center. “Have a risk-based approach where you base decisions on risk and medical history, and not on ethnic race.”

2. Prioritize education and awareness for patients.
Kalra’s team, for example, has created patient pamphlets explaining what statins are, why they’re critical, and what blood cholesterol targets patients should work to achieve. Since he works with a significant population of South Asian patients, where language can sometimes be a barrier, his team had these pamphlets translated into the patients’ native languages—a practice he recommends for any physician treating a significant number of patients who don’t speak English as their native language.

3. Engage in outreach.
For patients who lack reliable access to health care, outreach efforts can help bridge the gap. One example of a good outreach effort, Kalra says, is a weekend health fair held at a church or other community center, where community residents can get screenings for blood pressure and lipids.

4. Provide connections for needs that go beyond the clinic.
For patients of a lower socioeconomic status, factors like medication cost and transportation to medical care may be issues. Doctors can’t necessarily address these problems themselves—but they can and should connect patients to social workers and community health workers who are better equipped to help patients address these needs, Pandey says.

5. Be especially attentive to female patients.
While there are racial disparities in use of statins, there are also major gender disparities: Across racial groups, men consistently are more likely to receive a statin than are women.11,21,22 The risk categories of race and gender overlap, with the result that minority women are even less likely than minority men to receive a statin.10

Above all, Kalra says, the most important thing for physicians to do is simply become aware of the racial disparities in statin use and embrace change in their own practices.

“Physicians in general like to think that their house is in order, and if somebody else is not performing well, it’s not them,” Kalra says. “But across the board we see, no matter where you look in the United States, the rates of statin use in minorities, especially African Americans and Hispanics, are less than those for whites. So I would tell people to come up with a plan, to examine your own practice.”

“As long as physicians are conscious, we will make progress,” Kalra concludes. n

— Jamie Santa Cruz is a health and medical writer based in Parker, Colorado.

Disclosure: Vajravelu is an employee of the Department of Veterans Affairs. These comments do not necessarily represent the views of the Department of Veterans Affairs or the US government.

References
1. Heart disease facts. Centers for Disease Control and Prevention website. https://www.cdc.gov/heartdisease/facts.htm. Updated May 15, 2023. Accessed October 16, 2023.

2. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines [published correction appears in Circulation. 2019;140(11):e647-e648] [published correction appears in Circulation. 2020;141(4):e59] [published correction appears in Circulation. 2020;141(16):e773]. Circulation. 2019;140(11):e563-e595.

3. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients With valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines [published correction appears in Circulation. 2021;143(5):e228] [published correction appears in Circulation. 2021;143(10):e784]. Circulation. 2021;143(5):e35-e71.

4. Centers for Disease Control and Prevention. Health, United States Spotlight Racial and Ethnic Disparities in Heart Disease. https://www.cdc.gov/nchs/hus/spotlight/HeartDiseaseSpotlight_2019_0404.pdf. Published April 2019. Accessed October 16, 2023.

5. Total heart disease deaths by race/ethnicity. KFF website. https://www.kff.org/other/state-indicator/number-of-heart-disease-deaths-per-100000-population-by-raceethnicity-2/. Accessed October 6, 2023.

6. Kalra DK. Bridging the racial disparity gap in lipid-lowering therapy. J Am Heart Assoc. 2021;10(1):e019533.

7. Jose PO, Frank AT, Kapphahn KI, et al. Cardiovascular disease mortality in Asian Americans. J Am Coll Cardiol. 2014;64(23):2486-2494.

8. Rodriguez F, Maron DJ, Knowles JW, Virani SS, Lin S, Heidenreich PA. Association of statin adherence with mortality in patients with atherosclerotic cardiovascular disease. JAMA Cardiol. 2019;4(3):206-213.

9. Jacobs JA, Addo DK, Zheutlin AR, et al. Prevalence of statin use for primary prevention of atherosclerotic cardiovascular disease by race, ethnicity, and 10-year disease risk in the US: National Health and Nutrition Examination Surveys, 2013 to March 2020 [published correction appears in JAMA Cardiol. 2023;8(7):710]. JAMA Cardiol. 2023;8(5):443-452.

10. Frank DA, Johnson AE, Hausmann LRM, Gellad WF, Roberts ET, Vajravelu RK. Disparities in guideline-recommended statin use for prevention of atherosclerotic cardiovascular disease by race, ethnicity, and gender: a nationally representative cross-sectional analysis of adults in the United States. Ann Intern Med. 2023;176(8):1057-1066.

11. Raeisi-Giglou P, Jabri A, Shahrori Z, et al. Disparities in the prescription of statins in the primary care setting: a retrospective observational study. Curr Probl Cardiol. 2022;47(11):101329.

12. Minhas AMK, Ijaz SH, Javed N, et al. National trends and disparities in statin use for ischemic heart disease from 2006 to 2018: insights from National Ambulatory Medical Care Survey. Am Heart J. 2022;252:60-69.

13. Mann D, Reynolds K, Smith D, Muntner P. Trends in statin use and low-density lipoprotein cholesterol levels among US adults: impact of the 2001 National Cholesterol Education Program guidelines. Ann Pharmacother. 2008;42(9):1208-1215.

14. Lauffenburger JC, Robinson JG, Oramasionwu C, Fang G. Racial/ethnic and gender gaps in the use of and adherence to evidence-based preventive therapies among elderly Medicare Part D beneficiaries after acute myocardial infarction. Circulation. 2014;129(7):754-763.

15. Nanna MG, Navar AM, Zakroysky P, et al. Association of patient perceptions of cardiovascular risk and beliefs on statin drugs with racial differences in statin use: insights from the patient and provider assessment of lipid management registry. JAMA Cardiol. 2018;3(8):739-748.

16. Dorsch MP, Lester CA, Ding Y, Joseph M, Brook RD. Effects of race on statin prescribing for primary prevention with high atherosclerotic cardiovascular disease risk in a large healthcare system. J Am Heart Assoc. 2019;8(22):e014709.

17. Lewey J, Shrank WH, Bowry AD, Kilabuk E, Brennan TA, Choudhry NK. Gender and racial disparities in adherence to statin therapy: a meta-analysis. Am Heart J. 2013;165(5):665-678.e1.

18. Davis AM, Taitel MS, Jiang J, et al. A national assessment of medication adherence to statins by the racial composition of neighborhoods. J Racial Ethn Health Disparities. 2017;4(3):462-471.

19. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589.

20. Shen MJ, Peterson EB, Costas-Muñiz R, et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018;5(1):117-140.

21. Nanna MG, Wang TY, Xiang Q, et al. Sex differences in the use of statins in community practice. Circ Cardiovasc Qual Outcomes. 2019;12(8):e005562.

22. Peters SAE, Colantonio LD, Zhao H, et al. Sex differences in high-intensity statin use following myocardial infarction in the United States. J Am Coll Cardiol. 2018;71(16):1729-1737.

Are there racial differences in the effectiveness of statins?
Statins are known to be highly effective overall. However, there’s some racial variation in response to statins, in particular between Asians and Westerners. Research in Japanese and Chinese populations suggests that patients of Asian ethnicity need much lower doses of statins to achieve the same reduction in risk of cardiovascular events that Western patients would achieve with higher doses. This effect has been observed with all statins except pitavastatin, and it’s partly explained by genetics.1 Other research has reported differing effects of various lipid-lowering drugs in various ethnic groups due not only to genetics but also to such factors as socioeconomic status, education level, drug metabolism, and environmental factors (like diet, stress levels, and alcohol consumption).2 But while there are some differences in response to statins across racial groups, multiple trials indicate that statins are effective across various races. In the Justification for the Use of statins in Primary prevention an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial, which examined rosuvastatin in primary prevention, statins were shown to be effective for preventing cardiovascular events among whites, Blacks, Hispanics, and Asians alike.3 Other trials have found similar results.4,5 Sometimes, Black people are classified as being statin intolerant due to having elevated levels of creatinine kinase, and there’s concern that statins will cause myopathy in these individuals. However, according to Kalra, mildly elevated creatinine kinase levels are racially mediated and don’t usually indicate myopathy.6 In most Black Americans, even with such minor elevations in creatinine kinase, statins are appropriate, safe, and effective.

References
1. Naito R, Miyauchi K, Daida H. Racial differences in the cholesterol-lowering effect of statin. J Atheroscler Thromb. 2017;24(1):19-25.

2. Nanna MG, Navar AM, Zakroysky P, et al. Association of patient perceptions of cardiovascular risk and beliefs on statin drugs with racial differences in statin use: insights from the patient and provider assessment of lipid management registry. JAMA Cardiol. 2018;3(8):739-748.

3. Albert MA, Glynn RJ, Fonseca FA, et al. Race, ethnicity, and the efficacy of rosuvastatin in primary prevention: the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial. Am Heart J. 2011;162(1):106-14.e2.

4. Simon JA, Lin F, Hulley SB, et al. Phenotypic predictors of response to simvastatin therapy among African-Americans and Caucasians: the Cholesterol and Pharmacogenetics (CAP) Study. Am J Cardiol. 2006;97(6):843-850.

5. Deedwania PC, Gupta M, Stein M, Ycas J, Gold A; IRIS Study Group. Comparison of rosuvastatin versus atorvastatin in South-Asian patients at risk of coronary heart disease (from the IRIS Trial). Am J Cardiol. 2007;99(11):1538-1543.

6. Kalra DK. Bridging the racial disparity gap in lipid-lowering therapy. J Am Heart Assoc. 2021;10(1):e019533.