Racial Disparities in Heart Failure Prevalence and Mortality: insights from the National Health and Nutrition Examination Survey

Preamble:

Reference Papers:
- M. Talha et al. 2024
Study Objective: To examine racial and ethnic disparities in heart failure (HF) prevalence and outcomes among young to middle-aged adults in the United States.
Data Source: Cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2018.
Population: Adults aged 20-64 years with self-reported heart failure.
Race Categories:
- Non-Hispanic White (NH White)
- Non-Hispanic Black (NH Black)
- Hispanic
Outcomes:
- Prevalence of Heart Failure
- All-Cause Mortality
- Cardiac Mortality
Statistical Analysis: Multiple logistic regression and Cox proportional-hazards models were used to assess the independent association of race/ethnicity with heart failure (HF) prevalence and mortality outcomes, respectively, adjusted for:
- Demographics: Age, sex, race/ethnicity, insurance coverage, and waist circumference.
- Medical History: Hypertension, diabetes mellitus, hyperlipidemia, cancer, stroke, coronary artery disease, chronic obstructive pulmonary disease (COPD), and arthritis.
- Lifestyle Factors: Smoking status
Software: All statistical analyses were conducted using R Version 4.4.1, incorporating sampling weights, primary sampling units, and strata to ensure the accuracy and generalizability of the results.

Baseline Table:

Characteristic	Non-Hispanic White adults N = 1,180,184 ¹	Non-Hispanic Black adults N = 509,966 ¹	Hispanic adults N = 250,297 ¹	p-value ²	Overall N = 1,940,447 ¹
Age, mean (standard error)	57 (49 – 61)	52 (46 – 58)	52 (44 – 60)	0.026	55 (47 – 60)
Age groups, n (weighted %)				0.68
20-39	17 (11%)	14 (11%)	4 (7.0%)		35 (11%)
40-64	156 (89%)	168 (89%)	95 (93%)		419 (89%)
Sex, n (weighted %)				0.22
Men	104 (57%)	92 (47%)	54 (55%)		250 (54%)
Women	69 (43%)	90 (53%)	45 (45%)		204 (46%)
Education level, n (weighted %)				<0.001
Less than 9th grade	15 (6.9%)	7 (4.3%)	30 (30%)		52 (9.2%)
9-11th grade (Includes 12th grade with no diploma)	42 (18%)	41 (22%)	24 (22%)		107 (20%)
High school graduate/GED or equivalent	48 (30%)	55 (31%)	19 (25%)		122 (29%)
Some college or AA degree	52 (34%)	62 (34%)	22 (18%)		136 (32%)
College graduate or above	16 (11%)	17 (8.6%)	4 (5.3%)		37 (9.7%)
Insurance, n (weighted %)	155 (89%)	152 (81%)	80 (81%)	0.17	387 (86%)
Private, n (weighted %)	54 (100%)	44 (100%)	18 (92%)	0.039	116 (99%)
Medicare, n (weighted %)
Yes	53 (100%)	59 (100%)	25 (100%)		137 (100%)
Medicaid, n (weighted %)
Yes	57 (100%)	64 (100%)	29 (100%)		150 (100%)
BMI, n (weighted %)				0.33
<18.5	3 (1.2%)	2 (1.5%)	1 (1.3%)		6 (1.3%)
18.5–24.9	20 (11%)	28 (18%)	5 (7.4%)		53 (13%)
25–29.9	36 (20%)	27 (17%)	29 (30%)		92 (20%)
⩾30.0	100 (67%)	109 (63%)	53 (61%)		262 (66%)
Waist circumference, n (weighted %)				0.59
Normal	34 (21%)	35 (27%)	18 (24%)		87 (23%)
High	118 (79%)	113 (73%)	64 (76%)		295 (77%)
Smoking status, n (weighted %)				0.003
Never	39 (28%)	82 (47%)	46 (51%)		167 (36%)
Past	62 (36%)	46 (22%)	38 (29%)		146 (31%)
Current daily/nondaily smoker	72 (37%)	54 (32%)	15 (20%)		141 (33%)
¹ Median (Q1 – Q3); n (unweighted) (%)
² Design-based KruskalWallis test; Pearson’s X^2: Rao & Scott adjustment

Comorbidities Table:

Characteristic	Non-Hispanic White adults N = 1,180,184 ¹	Non-Hispanic Black adults N = 509,966 ¹	Hispanic adults N = 250,297 ¹	p-value ²	Overall N = 1,940,447 ¹
Hypertension, n/N (weighted %)	127/173 (72%)	157/182 (86%)	81/99 (81%)	0.033	365/454 (77%)
Mean systolic blood pressure (SE)	122 (114 – 135)	131 (115 – 150)	126 (115 – 137)	0.013	124 (115 – 139)
Mean diastolic blood pressure (SE)	71 (64 – 80)	77 (67 – 85)	74 (65 – 83)	0.010	73 (65 – 81)
Diabetes, n/N (weighted %)	72/170 (45%)	75/173 (39%)	51/95 (49%)	0.48	198/438 (44%)
Hyperlipidemia, n/N (weighted %)	103/166 (62%)	108/169 (63%)	53/90 (50%)	0.22	264/425 (61%)
Cancer, n/N (weighted %)	29/172 (19%)	17/182 (7.0%)	8/98 (6.0%)	0.002	54/452 (14%)
Stroke, n/N (weighted %)	37/173 (19%)	28/182 (14%)	14/98 (11%)	0.27	79/453 (17%)
Coronary artery disease, n/N (weighted %)	111/173 (60%)	92/181 (50%)	72/98 (71%)	0.036	275/452 (59%)
COPD, n/N (weighted %)	70/107 (60%)	46/96 (46%)	29/59 (47%)	0.24	145/262 (55%)
Arthritis, n/N (weighted %)	100/173 (59%)	96/182 (50%)	49/99 (39%)	0.022	245/454 (54%)
Obesity, n/N (weighted %)	100/159 (67%)	109/167 (63%)	53/89 (61%)	0.66	262/415 (65%)
¹ n (unweighted)/N (unweighted) (%); Median (Q1 – Q3)
² Pearson’s X^2: Rao & Scott adjustment; Design-based KruskalWallis test

Multivariable Logistic Regression:

Prevalence of HF:

Unadjusted ORs

Characteristic	OR (95% CI) ¹	p-value
Race/Ethnicity
Non-Hispanic White adults	—
Non-Hispanic Black adults	2.31 (1.79 to 2.98)	<0.001
Hispanic adults	0.86 (0.59 to 1.26)	0.45
¹ OR = Odds Ratio, CI = Confidence Interval

Adjusted ORs

Characteristic	OR (95% CI) ¹	p-value
Race/Ethnicity
Non-Hispanic White adults	—
Non-Hispanic Black adults	2.43 (1.57 to 3.78)	<0.001
Hispanic adults	1.81 (0.92 to 3.56)	0.083
Age	1.04 (1.02 to 1.07)	<0.001
Sex
Men	—
Women	0.86 (0.52 to 1.42)	0.54
Health Insurance (Yes/No)
Yes	—
No	1.12 (0.54 to 2.31)	0.75
Waist Circumference
Normal	—
High	1.06 (0.55 to 2.02)	0.86
Smoking Status
Never	—
Past	1.37 (0.72 to 2.62)	0.34
Current daily/nondaily smoker	1.43 (0.73 to 2.79)	0.29
Hypertension	2.20 (1.20 to 4.03)	0.011
Diabetes Mellitus	1.90 (1.22 to 2.95)	0.005
Hyperlipidemia	1.00 (0.63 to 1.60)	0.99
Cancer	1.23 (0.48 to 3.16)	0.66
Stroke	3.05 (1.60 to 5.81)	<0.001
Coronary Artery Disease	17.0 (9.72 to 29.6)	<0.001
Chronic Obstructive Pulmonary Disease	2.30 (1.35 to 3.89)	0.002
Arthritis	0.96 (0.56 to 1.63)	0.87
Obesity	1.80 (0.97 to 3.32)	0.060
¹ OR = Odds Ratio, CI = Confidence Interval

Cox Proportional Hazards Model

All-Cause Mortality

Unadjusted HRs

Stratified 1 - level Cluster Sampling design (with replacement)
With (174) clusters.
subset(dsgn, race %in% c("Non-Hispanic White adults", "Non-Hispanic Black adults", 
    "Hispanic adults") & RIDAGEYR >= 20 & RIDAGEYR <= 64 & heart_failure == 
    1)

Characteristic	HR (95% CI) ¹	p-value
Race/Ethnicity
Non-Hispanic White adults	—
Non-Hispanic Black adults	0.64 (0.42 to 0.98)	0.039
Hispanic adults	0.34 (0.17 to 0.67)	0.002
¹ HR = Hazard Ratio, CI = Confidence Interval

Adjusted HRs

Stratified 1 - level Cluster Sampling design (with replacement)
With (174) clusters.
subset(dsgn, race %in% c("Non-Hispanic White adults", "Non-Hispanic Black adults", 
    "Hispanic adults") & RIDAGEYR >= 20 & RIDAGEYR <= 64 & heart_failure == 
    1)

Characteristic	HR (95% CI) ¹	p-value
Race/Ethnicity
Non-Hispanic White adults	—
Non-Hispanic Black adults	0.53 (0.11 to 2.55)	0.43
Hispanic adults	0.52 (0.19 to 1.42)	0.20
Age	1.10 (1.03 to 1.17)	0.005
Sex
Men	—
Women	0.43 (0.15 to 1.23)	0.11
Health Insurance (Yes/No)
Yes	—
No	0.81 (0.14 to 4.69)	0.82
Waist Circumference
Normal	—
High	1.71 (0.34 to 8.66)	0.51
Smoking Status
Never	—
Past	0.76 (0.18 to 3.25)	0.72
Current daily/nondaily smoker	1.00 (0.17 to 5.82)	>0.99
Hypertension	0.20 (0.09 to 0.46)	<0.001
Diabetes Mellitus	0.96 (0.37 to 2.48)	0.94
Hyperlipidemia	0.58 (0.18 to 1.86)	0.36
Cancer	2.69 (0.79 to 9.11)	0.11
Stroke	0.55 (0.19 to 1.57)	0.27
Coronary Artery Disease	1.39 (0.37 to 5.17)	0.63
Chronic Obstructive Pulmonary Disease	4.23 (1.47 to 12.1)	0.007
Arthritis	1.25 (0.22 to 6.98)	0.80
Obesity	1.58 (0.51 to 4.92)	0.43
¹ HR = Hazard Ratio, CI = Confidence Interval

Cardiac Mortality

Unadjusted HRs

Stratified 1 - level Cluster Sampling design (with replacement)
With (174) clusters.
subset(dsgn, race %in% c("Non-Hispanic White adults", "Non-Hispanic Black adults", 
    "Hispanic adults") & RIDAGEYR >= 20 & RIDAGEYR <= 64 & heart_failure == 
    1)

Characteristic	HR (95% CI) ¹	p-value
Race/Ethnicity
Non-Hispanic White adults	—
Non-Hispanic Black adults	1.82 (0.89 to 3.69)	0.10
Hispanic adults	2.20 (0.67 to 7.27)	0.20
¹ HR = Hazard Ratio, CI = Confidence Interval

Adjusted HRs

Stratified 1 - level Cluster Sampling design (with replacement)
With (174) clusters.
subset(dsgn, race %in% c("Non-Hispanic White adults", "Non-Hispanic Black adults", 
    "Hispanic adults") & RIDAGEYR >= 20 & RIDAGEYR <= 64 & heart_failure == 
    1)

Characteristic	HR (95% CI) ¹	p-value
Race/Ethnicity
Non-Hispanic White adults	—
Non-Hispanic Black adults	6.05 (1.87 to 19.6)	0.003
Hispanic adults	0.28 (0.06 to 1.32)	0.11
Age	1.06 (0.99 to 1.14)	0.087
Sex
Men	—
Women	2.89 (1.17 to 7.11)	0.021
Health Insurance (Yes/No)
Yes	—
No	0.82 (0.18 to 3.73)	0.79
Waist Circumference
Normal	—
High	0.61 (0.10 to 3.54)	0.58
Smoking Status
Never	—
Past	9.30 (4.32 to 20.0)	<0.001
Current daily/nondaily smoker	3.56 (1.02 to 12.4)	0.047
Hypertension	0.58 (0.18 to 1.91)	0.37
Diabetes Mellitus	4.15 (1.39 to 12.4)	0.011
Hyperlipidemia	0.14 (0.06 to 0.33)	<0.001
Cancer	0.00 (0.00 to 0.00)	<0.001
Stroke	0.07 (0.02 to 0.25)	<0.001
Coronary Artery Disease	28.8 (13.2 to 62.9)	<0.001
Chronic Obstructive Pulmonary Disease	0.13 (0.05 to 0.34)	<0.001
Arthritis	0.42 (0.15 to 1.16)	0.10
Obesity	27.8 (9.43 to 82.1)	<0.001
¹ HR = Hazard Ratio, CI = Confidence Interval

Kaplan-Meier Curves:

All-Cause Mortality:

Cardiac Mortality: