Racial and Ethnic Disparities in Established Cardiovascular Disease

Published Jul 14, 2025Updated Sep 30, 2026Last reviewed Jul 14, 2025

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Racial and ethnic disparities in cardiovascular disease involve both the burden of illness and access to effective treatment. For someone who already has coronary disease, heart failure or a prior stroke, the practical priority is a treatment and follow-up plan that fits the diagnosis and can actually be obtained and followed.

Race and ethnicity describe populations and social experiences; they do not replace an individual's blood pressure, cholesterol, kidney function, symptoms or treatment history. The American Heart Association identifies structural racism, unequal access to care and the conditions in which people live as contributors to cardiovascular inequity. [1]

What do the population studies show?

Different studies answer different questions. A stroke death rate, the chance of a first cardiovascular event and the proportion receiving a prescription are separate outcomes.

Evidence	Population and finding	What it tells us
CDC stroke surveillance	The risk of a first stroke is nearly twice as high in non-Hispanic Black adults as in White adults. [2]	Prevention and timely access to stroke care remain important priorities.
NCHS mortality analysis	In 2022, Black men aged 45 to 64 had stroke death rates two to three times those of other racial and Hispanic-origin groups within each U.S. region. [3]	The disparity is visible in midlife mortality, not just in the number of older survivors.
UK Biobank prospective study	Among 8,124 South Asian and 449,349 European-ancestry adults without baseline ASCVD, events occurred in 6.8% and 4.4%, respectively, over a median 11 years. [4]	Ancestry and population context can identify patterns that warrant closer assessment.
Hispanic Community Health Study/Study of Latinos	Among 15,079 participants with complete data, 80% of men and 71% of women had at least one major cardiovascular risk factor. Results differed across six background groups. [5]	A single Hispanic or Latino average can hide meaningful variation.

The South Asian study was conducted in a UK cohort. Its results should be understood in that population, rather than converted into a fixed risk multiplier for every South Asian patient. Similarly, the Hispanic/Latino study measured risk factors in selected U.S. communities; its percentages are not a current national mortality estimate.

For a person with established disease, the next question is more immediate: are the indicated treatments reaching the patient, and are they achieving their intended effects?

Where can treatment gaps be measured?

A 2024 study followed 133,158 adults after a first ASCVD event in a Northern California health system. Across racial and ethnic groups, fewer than 60% received a statin prescription, fewer than 25% received a high-intensity statin prescription and fewer than 30% reached LDL cholesterol below 70 mg/dL during the first year. Black patients had the lowest reported proportions for any statin prescription, 46.7%, and LDL below 70 mg/dL, 10.7%. [6]

The study also separated several Asian and Hispanic groups, showing why broad categories can obscure differences. It describes prescribing and recorded cholesterol outcomes in one system. A prescription record does not establish that the medicine was affordable, dispensed or taken.

A useful follow-up therefore checks the entire sequence: recommendation, prescription, pharmacy access, actual use, tolerability and repeat measurement. A missing link can require a different solution from simply increasing a dose.

Established disease needs secondary prevention

Primary prevention aims to prevent a first event. Secondary prevention addresses someone who already has disease. These should not be mixed together.

The AHA PREVENT equations estimate risk in adults aged 30 to 79 without known cardiovascular disease. They do not include race as a predictor. Their role is not to decide whether a person with a previous heart attack deserves treatment. [7]

The 2026 dyslipidemia guideline replaces the 2018 cholesterol guideline, uses PREVENT for primary-prevention decisions and restores LDL and non-HDL cholesterol treatment goals matched to risk. For established ASCVD, the lipid plan should follow the secondary-prevention pathway, including review of treatment response and the need for additional therapy. [8]

For an appointment, bring the diagnosis, prior procedure or hospital discharge record, current medicines and latest laboratory results. Ask which treatment target applies and when it will be rechecked. These questions are more useful than applying a first-event risk calculator to an event that has already happened.

Heart failure also requires its own diagnosis-specific plan. Treatment for reduced ejection fraction commonly combines medicines acting through different pathways, including an ARNI or ACE inhibitor/ARB, an evidence-based beta blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor when appropriate. Race does not replace assessment of kidney function, blood pressure, symptoms and tolerability. [9]

What do ALLHAT and A-HeFT actually establish?

Two major trials are often cited when discussing race and cardiovascular medicines.

ALLHAT compared initial blood-pressure treatments in 33,357 adults aged 55 or older with hypertension and another coronary risk factor. About 35% were Black. There was no significant difference between treatments in the primary coronary outcome. In the Black subgroup, stroke risk was higher with lisinopril than chlorthalidone, with a relative risk of 1.40. [10]

That finding concerns the tested treatment strategies and population. It is not a reason to stop an ACE inhibitor prescribed for a separate indication such as heart failure without reviewing that indication and the full regimen.

A-HeFT randomized 1,050 self-identified Black patients with advanced symptomatic heart failure to added hydralazine plus isosorbide dinitrate or placebo. Both groups received standard heart-failure therapy. Mortality was 6.2% with the added combination and 10.2% with placebo; first heart-failure hospitalization was also reduced. [11]

The trial supports an additional treatment option for the population studied. Because it enrolled only Black patients, it did not compare the size of the treatment effect across racial groups. The treatment is added to an appropriate heart-failure plan, not used to replace its other components. [9,11]

Turn a treatment gap into a specific next step

Use the following questions to identify what needs to change:

Question	Practical next step
Was the treatment recommended but never started?	Check the prescription, pharmacy availability and out-of-pocket cost.
Was it started and then stopped?	Review the reason, including symptoms, refill problems or unclear instructions.
Is treatment being taken but the target remains unmet?	Review the regimen, measurement and next treatment option with the clinician.
Was a referral placed but never completed?	Confirm scheduling, transport, appointment availability and language support.
Are similar patients receiving different care within a practice?	Compare eligible patients' prescribing, follow-up and outcomes, including documented reasons for differences.

For patients, it can help to leave with a written medicine list, the next test or appointment date and a clear contact for prescription problems. For practices, a prescribing rate alone is only one part of the picture: refill access and completed follow-up show whether the plan reaches daily life.

Stroke symptoms still need immediate action

Sudden one-sided weakness, facial drooping or difficulty speaking requires emergency assessment. Call 911 rather than waiting for the next appointment, including when symptoms improve. New chest pressure or other symptoms suggesting a heart attack also need emergency care. [2,12]

After the acute event, follow-up should connect the hospital plan with ongoing blood-pressure care, the appropriate antithrombotic treatment and other secondary-prevention measures. The exact regimen depends on the event's cause. A reliable handoff, filled prescriptions and a completed follow-up visit are concrete places to reduce gaps in care.