Statement Highlights:
Embargoed until 4 a.m. CT / 5 a.m. ET Wednesday, May 31, 2023
DALLAS, May 31, 2023 — Heart health risks emerge early in life in American Indian/Alaska Native (AI/AN) women and are increased by social factors — like high levels of experiencing violence and traumatic life events — and disproportionately high rates of Type 2 diabetes, smoking and obesity, according to a new scientific statement published today in Circulation: Cardiovascular Quality and Outcomes , a peer-reviewed American Heart Association journal.
Cardiovascular disease is the leading cause of pregnancy-related death in the U.S. and the second leading cause of death in AI/AN women in the U.S. Overall, AI/AN individuals are 50% more likely to be diagnosed with premature cardiovascular (CVD) disease than their white counterparts. According to the statement, more than 60% of AI/AN women have suboptimal heart health when they become pregnant, which is strongly related to the development of heart disease later in life.
“Cardiovascular disease rates are particularly high in AI/AN women of reproductive age, for whom early detection and management of CVD remain paramount for improving cardiovascular health and reducing premature death,” said Garima Sharma, M.D., FAHA, chair of the writing committee for this scientific statement. “We hope to bring to the forefront the disproportionate burden of CVD, adverse pregnancy outcomes and poor maternal health in American Indian and Alaska Native women as maternal mortality in the United States continues to increase.”
Sharma is the director of women’s cardiovascular health and cardio-obstetrics at Inova Health System in Falls Church, VA, and adjunct associate professor at the Ciccarone Center for the Prevention of Cardiovascular Disease at Johns Hopkins University School of Medicine in Baltimore.
This is the first time maternal cardiovascular health in AI/AN individuals has been addressed in an American Heart Association scientific statement. The writing group reported on cardiovascular health status among AI/AN women based on the Association’s optimal heart health metrics called Life’s Essential 8 . The statement also highlights underrecognized risks and social determinants of health that disproportionately affect AI/AN individuals. These environmental risk factors include food insecurity, inadequate access to care, psychological health factors (anxiety, depression), posttraumatic stress disorder, substance abuse, intimate partner violence, institutional and structural racism, and the historical context of colonization, dominance and exploitation of AI/AN people and lands.
Social determinants of health
The statement stresses the impact of social determinants of health on mental health and substance use disorders in AI/AN women. Despite their geographic and cultural differences, AI/AN women often share common experiences of racism and discrimination, which contribute to an overall environment of mistreatment and toxic stress, according to the statement.
More than 84% of AI/AN women experience violence in their lifetime, which may be reflected in the high prevalence of mood disorders, anxiety, and substance and alcohol use disorders in this population.
AI/AN women are also disproportionately more likely to have experienced a high number of adverse childhood experiences, such as neglect, abuse or having a parent in prison, which increase the likelihood of high-risk behaviors (cigarette smoking, substance use, etc.) and chronic disease in adulthood.
“AI/AN women’s mental and behavioral health disparities reflect the toxic stress and trauma of violence,” said Sharma. “Maternal care for AI/AN women must address traditional as well as social and cultural determinants of health. Common CVD risk factors such as Type 2 diabetes, obesity, smoking and premature atherosclerosis are aggravated in AI/AN individuals by chronic stress, intergenerational trauma, violence, adverse childhood experiences and food insecurity.”
Traditional risk factors
Life’s Essential 8 metrics for optimal cardiovascular health include blood pressure, cholesterol, blood glucose/Type 2 diabetes, weight, diet, physical activity, nicotine exposure and sleep duration. While rates of high blood pressure and cholesterol disorders are similar among AI/AN women compared to women of other races, and most report leisure or work-related physical activity, other factors have a significant impact on their heart health:
Risks surrounding pregnancy
The statement highlights pregnancy risks related to cardiovascular health in AI/AN women:
Addressing maternal health in AI/AN women
The statement makes several recommendations about ways to address cardiovascular risks among AI/AN women, including:
“Health systems and community-based organizations that identify trauma and teach and celebrate resilience are essential to address mental and behavioral health needs and to promote healing of AI/AN women, families and communities,” the statement says.
Evidence used in developing the statement is limited by the small numbers of AI/AN women in clinical trials and the lack of health registries with data separated for the AN/AI population.
“We need to understand the health status of AI/AN populations and work collaboratively to improve cultural competency among our clinicians and partner with policymakers, health care professionals, local communities and tribal leadership to design better studies and include the voices of these patients in providing appropriate care,” said Sharma.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; the Council on Hypertension; the Council on Cardiovascular and Stroke Nursing; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; and the Council on Quality of Care and Outcomes Research. American Heart Association scientific statements promote greater awareness about cardiovascular disease and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.
Co-authors are Vice Chair Allison Kelliher, M.D.; Jason Deen, M.D.; Tassy Parker, Ph.D., R.N.; Tracy Hagerty, M.D.; Eunjung Esther Choi, M.D.; Ersilia M. DeFilippis, M.D.; Kimberly Harn, M.Ed., R.T. (R), (M.R.); Robert Dempsey, M.D., FAHA; and Donald M. Lloyd-Jones, M.D., Sc.M., FAHA. Authors’ disclosures are listed in the manuscript.
The Association receives funding primarily from individuals. Foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers, and the Association’s overall financial information are available here .
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About the American Heart Association
The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations, and powered by millions of volunteers, we fund innovative research, advocate for the public’s health and share lifesaving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us on heart.org , Facebook , Twitter or by calling 1-800-AHA-USA1.
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Circulation Cardiovascular Quality and Outcomes
Status of Maternal Cardiovascular Health in American Indian and Alaska Native Individuals: A Scientific Statement From the American Heart Association