Chapter 8: Cardiovascular System

Background

Cardiovascular disease presents a growing health challenge for Indigenous adults in Canada. It has a prevalence rate of 7.1% among Indigenous adults compared to 5.0% in the broader population, signalling a disparity in disease burden and outcomes (Foulds et al., 2018). The disease manifests through alterations in heart structure and function, decreased coronary perfusion, hypertrophy, and decreased kidney perfusion. It often develops before clinical symptoms become apparent (Foulds et al., 2018).

The Social Determinants of Health in Relation to Cardiovascular Health

Historically, race has influenced the way cardiovascular disease risk is assessed, leading to disparities in treatment between racialized patients and their White counterparts in North America (Allana et al., 2021; Caceres et al., 2022; Chadha et al., 2020; d’Entremont et al., 2021; Javed et al., 2022; Panza et al., 2019; Rooks et al., 2008). Until recently, the American Heart Association (AHA) factored in a patient’s African American identity when assessing cardiovascular risk (AHA, 2024). However, this practice was not only impractical to implement but also based on flawed scientific assumptions. It resulted in delayed or withheld treatments and interventions (Chadha et al., 2020; Javed et al., 2022). The AHA’s vague criteria for defining “African American” further complicated matters, as it failed to distinguish between individuals of various African descents. This ambiguity extended to the broader issue of race, considering the diversity within African communities and the complexity of racial identity. These inconsistencies highlight the importance of uniform standards in risk assessment to ensure equitable treatment for all patients.

The outdated belief that higher sodium production in Black patients led to increased blood pressure was disproven by the lack of corresponding hypertension rates in West Africa, where enslaved ancestors originated (Chadha et al., 2020). This dispels the myth of a genetic difference specific to Black patients that causes an increase in their blood levels of sodium (Chadha et al., 2020). Organizations like the AHA have only very recently revised their risk assessment protocols. They are no longer incorporating race as a factor. The Canadian Cardiovascular Society also avoids race-based risk assessment in its calculators (Foulds et al., 2018; Henry et al., 2022; Khan et al., 2023).

In Canada, racialized patients are less frequently offered cardiac catheterization for acute coronary syndrome treatment, often due to higher rates of comorbidities (d’Entremont et al., 2021). Additionally, chronic stress and sustained sympathetic nervous system activation contribute to an increased risk of cardiovascular disease (Panza et al., 2019).

Culturally Responsive Practice Points for Health Care Providers

Objective Assessment

Objective assessment methods are similar in nature for all patients. However, the indications of pallor and cyanosis exhibit distinctions. Cyanosis, despite its visibility, is not a reliable marker for detecting hypoxemia levels (Henry et al., 2022). Previously, clinical signs of cyanosis were used to gauge hypoxemia and decreased tissue perfusion, but this approach has proven to be highly unreliable (Henry et al., 2022). Factors such as poor lighting, dark skin tones, or chronic anemia can lead to the misinterpretation or oversight of cyanosis (Henry et al., 2022). Hypoxemia is more accurately assessed through rapid blood gas analysis. Consequently, clinicians should not solely depend on the presence of cyanosis to ascertain the presence of hypoxemia in patients. It’s worth noting that SPO2 monitors tend to overestimate SaO2 in Black patients, which can lead to suboptimal outcomes (Henry et al., 2022).

On the other hand, pallor often signifies anemia and serves as a cost-effective and swift indicator for further evaluation of hemoglobin and hematocrit levels, especially if these tests are readily accessible in the patient’s primary care setting (Stoltzfus et al., 1999). Assessing pallor in patients with darker skin can be done by observing palms and conjunctiva for pale appearance. However, if paleness in these areas is noted, it is important to confirm anemia with blood work before treatment is prescribed (Stoltzfus et al., 1999).

Subjective Assessment

In creating a subjective assessment for cardiovascular health, it’s important to approach patients with cultural humility and an understanding of the social determinants of health that may affect marginalized groups (Allana et al., 2021; Caceres et al., 2020, 2022). Questions should be framed in a way that acknowledges and respects a patient’s background, experiences, and individual health needs. For instance, health care providers could ask about access to nutritious food, safe environments for physical activity, and stress factors that may contribute to cardiovascular risk. It’s also important to inquire about the patient’s understanding of their health and any barriers they face in managing their condition. These barriers could include access to medication and adherence to treatment or access to health care services.

Here are more questions that health care providers can incorporate into a subjective cardiovascular assessment for marginalized patients:

1. “How do you feel about the health care you’ve received in the past? Are there any changes you wish to see?”
2. “Can you share any home remedies or traditional practices you use for your health? How do they impact your heart health?”
3. “What are your main sources of support when it comes to your health?”
4. “Have you encountered any obstacles in getting to your medical appointments?”
5. “How does your work environment or job affect your stress levels and overall heart health?”
6. “Are there any financial constraints that make it difficult for you to get your medications or follow a heart-healthy diet?”
7. “What are your feelings about exercise and physical activity? Do they fit into your life?”
8. “How does your community view heart health, and how does that affect your health behaviours?”

These questions are aimed at helping nurses understand patients’ lived experience and consider the intersection of race, environment, and socioeconomic status with health outcomes. They encourage a dialogue that can reveal information that is critical for tailoring care to everyone’s circumstances.

An excellent resource to help patients understand what screenings they may need and when can be found at https://www.screening.ca/en. Using this resource can help empower patients to advocate for health screening services for themselves or their loved ones (Persaud et al., 2023). 

References

American Heart Association (2024, March 12). Race, racism and risk prediction for cardiovascular disease. https://newsroom.heart.org/news/race-racism-and-risk-prediction-for-cardiovascular-disease

Allana, S., Ski, C. F., Thompson, D. R., & Clark, A. M. (2021). Bringing intersectionality to cardiovascular health research in Canada. CJC Open, 3(12), S4–S8. https://doi.org/10.1016/j.cjco.2021.08.016

Caceres, B. A., Ancheta, A. J., Dorsen, C., Newlin-Lew, K., Edmondson, D., & Hughes, T. L. (2022). A population-based study of the intersection of sexual identity and race/ethnicity on physiological risk factors for CVD among U.S. adults (ages 18–59). Ethnicity and Health, 27(3), 617–638. https://doi.org/10.1080/13557858.2020.1740174

Caceres, B. A., Streed, C. G., Corliss, H. L., Lloyd-Jones, D. M., Matthews, P. A., Mukherjee, M., Poteat, T., Rosendale, N., & Ross, L. M. (2020). Assessing and addressing cardiovascular health in LGBTQ adults: A scientific statement from the American Heart Association. Circulation, 142(19), E321–E332. https://doi.org/10.1161/CIR.0000000000000914

Chadha, N., Lim, B., Kane, M., & Rowland, B. (2020). Toward the abolition of biological race in medicine: Transforming clinical education, research, and practice. Othering & Belonging Institute, University of California, Berkeley. https://belonging.berkeley.edu/sites/default/files/race_in_medicine.pdf?

d’Entremont, M. A., Wee, C. C., Nguyen, M., Couture, É. L., Lemaire-Paquette, S., Kouz, S., Afilalo, M., Rinfret, S., Schampaert, E., Mansour, S., Montigny, M., Eisenberg, M., Lauzon, C., Déry, J. P., L’Allier, P., Tardif, J. C., & Huynh, T. (2021). Racial disparities in acute coronary syndrome management within a universal healthcare context: Insights from the AMI-OPTIMA Trial. CJC Open, 3(12), S28–S35. https://doi.org/10.1016/j.cjco.2021.07.006

Foulds, H. J. A., Bredin, S. S. D., & Warburton, D. E. R. (2018). Cardiovascular dynamics of Canadian Indigenous peoples. International Journal of Circumpolar Health, 77(1). https://doi.org/10.1080/22423982.2017.1421351

Henry, N. R., Hanson, A. C., Schulte, P. J., Warner, N. S., Manento, M. N., Weister, T. J., & Warner, M. A. (2022). Disparities in hypoxemia detection by pulse oximetry across self-identified racial groups and associations with clinical outcomes. Critical Care Medicine, 50(2), 204–211. https://doi.org/10.1097/CCM.0000000000005394

Javed, Z., Haisum Maqsood, M., Yahya, T., Amin, Z., Acquah, I., Valero-Elizondo, J., Andrieni, J., Dubey, P., Jackson, R. K., Daffin, M. A., Cainzos-Achirica, M., Hyder, A. A., & Nasir, K. (2022). Race, racism, and cardiovascular health: Applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease. Circulation: Cardiovascular Quality and Outcomes, 15(1), E007917. https://doi.org/10.1161/CIRCOUTCOMES.121.007917

Khan, S. S., Coresh, J., Pencina, M. J., Ndumele, C. E., Rangaswami, J., Chow, S. L., Palaniappan, L. P., Sperling, L. S., Virani, S. S., Ho, J. E., Neeland, I. J., Tuttle, K. R., Singh, R. R., Elkind, M. S. V., & Lloyd-Jones, D. M. (2023). Novel prediction equations for absolute risk assessment of total cardiovascular disease incorporating cardiovascular-kidney-metabolic health: A scientific statement from the American Heart Association. Circulation, 148(24), 1982–2004). https://doi.org/10.1161/CIR.0000000000001191

Panza, G. A., Puhl, R. M., Taylor, B. A., Zaleski, A. L., Livingston, J., & Pescatello, L. S. (2019). Links between discrimination and cardiovascular health among socially stigmatized groups: A systematic review. PLoS ONE, 14(6), e0217623. https://doi.org/10.1371/journal.pone.0217623

Persaud, N., Sabir, A., Woods, H., Sayani, A., Agarwal, A., Chowdhury, M., de Leon-Demare, K., Ibezi, S., Hameed Jan, S., Katz, A., LaFortune, F. D., Lewis, M., McFarlane, T., Oberai, A., Oladele, Y., Onyekwelu, O., Peters, L., Wong, P., & Lofters, A. (2023). Preventive care recommendations to promote health equity. Canadian Medical Association Journal, 195(37), E1250–E1273. https://doi.org/10.1503/cmaj.230237

Rooks, R. N., Simonsick, E. M., Klesges, L. M., Newman, A. B., Ayonayon, H. N., & Harris, T. B. (2008). Racial disparities in health care access and cardiovascular disease indicators in black and white older adults in the health ABC study. Journal of Aging and Health, 20(6), 599–614. https://doi.org/10.1177/0898264308321023

Stoltzfus, R. J., Edward-Raj, A., Dreyfuss, M. L., Albonico, M., Montresor, A., Dhoj Thapa, M., West, K. P., Chwaya, H. M., Savioli, L., & Tielsch, J. (1999). Clinical pallor is useful to detect severe anemia in populations where anemia is prevalent and severe. The Journal of Nutrition, 129(9), 1675–1681. https://doi.org/10.1093/jn/129.9.1675