key: cord-0948705-9keet8ih
authors: Ferdinand, Keith C.; Nasser, Samar A.
title: African American COVID-19 Mortality: A Sentinel Event
date: 2020-04-21
journal: J Am Coll Cardiol
DOI: 10.1016/j.jacc.2020.04.040
sha: 91f58ab18815426c3cccd864d886341df2cef405
doc_id: 948705
cord_uid: 9keet8ih

nan

The tragic higher COVID-19 mortality in African Americans (AAs) and other racial/ethnic minorities confirms inadequate societal efforts to eliminate disparities in cardiovascular disease (CVD) and is a sentinel event, highlighting deep-rooted failures U.S. healthcare failures. The Joint Commission defines a sentinel event as an unexpected occurrence resulting in death or serious physical or psychological injury, or the risk thereof (1) . Conventionally identified sentinel events, such as unintended retention of foreign objects and fall-related events, are used to evaluate quality in hospital care. Similarly, disparate AA COVID-19 mortality reflects longstanding, unacceptable U.S. racial/ethnic and socioeconomic CVD inequities and unmasks system failures and unacceptable care to be caught and mitigated. While it is unclear if AAs are infected more often, ssocial determinants of health are powerful predictors of COVID-19 infectivity and mortality. The impact of COVID-19 goes well beyond the viral infection itself, reflecting the dynamics of a long-standing adverse host-environment, including access to limited resources (i.e., money, food, education, healthcare, job flexibility), making disadvantaged communities more vulnerable in the pandemic. African

Americans and many people of color are more likely to provide high risk essential services, including low-wage jobs that cannot be done remotely and have fewer financial resources to draw on in the event of health problems or economic disruption. The underlying co-morbid conditions, such as cardiovascular disease, hypertension, diabetes, obesity, and asthma, are reflections of structural societal flaws beyond simply poor lifestyle choices, ultimately lead to higher COVID-19 AA mortality, in both urban and rural environments. People of color are not genetically nor biologically predisposed to get COVID-19, but are socially prone to coronavirus exposure and have higher incidence of the very co-morbidities fueling complications. Notably, minorities are more likely to be uninsured compared to non-Hispanic whites, and uninsured adults are less likely to have CVD risks controlled. The comorbidities that make COVID-19 more deadly are linked to the segregation and concentrated poverty that still mark these disparate communities. Hence, maintenance and continuity of CVD care during this crisis is absolutely required.

Mechanistically, patients with diabetes, often associated with obesity and hypertension, maybe more susceptible to an inflammatory storm eventually leading to rapid progression and adverse prognosis of COVID-19 (4). Thus, effective control of these metabolic parameters may represent a specific and mechanistic approach to prevent and ameliorate the acute effects of COVID-19. Despite advancement in risk factor identification and availability of effective therapies, mortality associated with uncontrolled and more severe HTN in AAs, with co-morbid diabetes, is causal for stroke, heart failure, chronic kidney disease, and end-stage renal disease.

Although hypertension is the most prevalent and potent risk factor in AAs (5), the COVID-19hypertension link is not necessarily a causal relationship, since age is such a powerful risk for both conditions. Regardless, hypertension control remains an essential component of optimal health. Unfortunately, COVID-19 exposed the pernicious disparities in the health of our multiethnic society. Ahmad et al. observed the correlation between poverty and heart failure outcomes, with lower socioeconomic status linked to increased CVD-related hospitalization and mortality (6) .

For decades American healthcare has failed minority communities in both primary and secondary CVD prevention. It is essential in this pandemic and in the future that clinicians ensure continuation of CVD medications including anti-hypertensives, antiplatelets and anticoagulation medications, statins and other lipid modifying agents, and if possible, prescribe 90-day supplies with sufficient refills.

Recent national data demonstrate that 90% of hospitalized COVID-19 patients have some underlying condition (7, Figure 2 ). Disturbingly, higher mortality from COVID-19 has been locally documented in AA populations from New Orleans, LA, Chicago, IL, Milwaukee, WI and Detroit, MI and even rural Albany, GA. For example, 70% of the people who have died from coronavirus in Louisiana are black, a striking disparity for a state where AAs make up only 32% of the population (http://ldh.la.gov/coronavirus, accessed APR 13, 2020). Similarly, AAs compromise 14% of the population in Michigan, but represent 40% of COVID-19 deaths, and like LA, Michigan recently formed a task force to tackle racial COVID-19 disparities (KFF, 2020). The top 3 underlying conditions among COVID-19 LA deaths are hypertension (59.76%), diabetes (38.10%) and chronic kidney disease (22.50%) (8). In view of a specific medical code for COVID-19, documenting racial/ethnic variations in testing and treatment is essential.

Furthermore, once there is a vaccine, these surveillance data must be used to monitor disparities and identify discrimination.

The American College of Cardiology (ACC) Cardiosmart COVID-19 materials (9) 

Targeted culturally-sensitive, literacy-level appropriate mitigation education: social distancing, masks,hand washing to minimize exposure risk Mandated personal protection for essential service workers: custodial and clerical staff, mass transit operators, sanitation workers, food service workers Financial protection and permanent insurance for presently non-covered workers Targeted testing in crowded housing environments with limited ability to socially isolate Testing beyond symptomatic individuals and development of walk-in facilities, considering disadvantaged persons may lack private automobiles for transportation Testing essential workers and their family members for diagnosis and immunity as employment expands Encourage team-approach telemedicine including, home BP monitoring,home scales and encourage heart-healthy eating patterns and control CVD risk factorsand seek emergency care for CVD concerns outside of COVID-19 Identify and suggest low-cost or free virtual physical activities online Encourage thermometers and even pulse oximeters (although limited availability) to monitor COVID-19 status in affected patients Support local and state task forces to correct racial/ethnic COVID-19 disparities

Sentinel event policy and procedures

Disparities, hospital financing and more

Report of the Secretary's Task Force on Black & Minority Health

US Department of Health and Human Services

Endocrine and metabolic link to coronavirus infection

Regional Variation in the Association of Poverty and Heart Failure Mortality in the 3135 Counties of the United States

African American Heart Disease and Stroke Fact Sheet

Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease

The American College of Cardiology