Cardiovascular risk calculator can lead to overtreatment of Black patients, study finds

A risk calculator from the American College of Cardiology and the American Heart Association gives Black patients much worse cardiovascular health predictions than white patients, even when their risk profiles are identical apart from race, according to a study published in the Lancet this month.

The Boston University School of Medicine authors who conducted the analysis describe these differences as “biologically implausible” in their report. These findings illustrate another way Black patients tend to be treated differently than white patients. Unlike previous analyses showing Black patients are likely to receive insufficient care, this new study provides an example of this population being at risk for too much medical care.

“Although the direction of this potential bias might seem somewhat reassuring (relative to the opposite scenario of Black individuals not receiving statins relative to their white counterparts), the risks associated with over-treatment—i.e., financial, psychological, side-effects and quality of life—are not trivial,” the authors wrote.

The American College of Cardiology and the American Heart Association didn’t respond to requests for comment.

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Researchers created about 50,000 combinations of different risk factors through the calculator and scrutinized those that generated scores high enough to signal to physicians that patients needed preventive care, according to a Boston University School of Medicine news release.

Factors like cholesterol levels, history of smoking and race are tallied into a calculator created by the two medical groups. If the score is above a 7.5% for having an event like a heart attack or stroke over the next 10 years, the American College of Cardiology and the American Heart Association recommend treatments such as statins.

In about 20% of the risk factor combinations, “Black-white differences in risk predicted by these equations can result in different treatment decision,” according to the Boston University School of Medicine. “More often Blacks would be prescribed a statin because they are deemed to be at higher risk. The difference in predicted risk (Blacks vs. Whites with identical risk factors) can be as large as 22.8 percent for men and 26.8 percent for women.”

Race in itself should not be a stand-in for actual risk-factors of heart disease, which could include some measure of the social determinants of health like housing security, food insecurity and economic challenges, the researchers wrote.

“Race should be replaced in any risk prediction equation by the various potentially causal factors that race represents, and that can be targeted with interventions,” the authors write.

These findings come as there is an increased push to capture race data in healthcare settings—and warnings that applying those data in predictive algorithms may not be appropriate. Race doesn’t necessarily equate with socioeconomic status, genetics or environment, and could be driving either over- or undertreatment.

In an accompanying editorial, the Lancet Digital Health editors committed to collecting demographic data such as including race and ethnicity for all research papers submitted, and require authors to explain why that information isn’t available in cases it’s not included.

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