Discovering the Full Spectrum of Cardiovascular Disease

The US population is exceptionally rich in cultural diversity, and that diversity is increasing rapidly. Nearly 33% of the US population self-identifies as a member of a racial or an ethnic minority.1 Trends in US Census data for the past 30 years point to the continual increase in the number of diverse groups. Roughly 1 million immigrants enter the United States each year; by 2000, there were 32 million immigrants. Some regions are extraordinarily diverse: For example, in Los Angeles County, Calif, 140 nationalities have been documented. In terms of future population trends, Latinos, Asians, and their subgroups will at least double, if not triple, in population size by the year 2050.2 Likewise, people of predominantly African descent and Native Americans will show marginal increases in population size. The number of individuals who claim membership in at least 2 ethnic groups will increase 10% by 2050, and racial/ethnic minorities will constitute 50% of the US population. The aging of the “baby boom” population segment of the United States, which is defined as people born between 1946 and 1964, will create increasing numbers of cases of cardiovascular diseases (CVD) and escalating demand for screening and treatment services. A broad (eg, World Health Organization) definition of health as physical, mental, and social well-being must guide advocacy efforts to define policy and programmatic strategies to eliminate racial/ethnic disparities in CVD because healthcare practices and policies do not sufficiently address racial/ethnic disparities in health status.3 In fact, most of the determinants of health status fall outside the healthcare sector. This point is graphically demonstrated in the framework for a comprehensive public health strategy presented in A Public Health Action Plan to Prevent Heart Disease and Stroke, released in April 2003. The purpose of this article is to set an advocacy and action agenda for research and service efforts with regard to disparities in CVD. In endeavoring to systematically explore and delineate these efforts, the authors use 3 categories of prevention: primary, secondary, and tertiary.4 It should be recognized, however, that these efforts extend well beyond the clinical encounter to embrace a variety of regulatory, policy, and practice changes in sectors outside health care and even health services. Primary prevention strategies are those that ameliorate the root causes of disease before its development, those that are mainly population based. Secondary prevention aims at detecting disease or disease precursors early, when intervention is most effective. Tertiary prevention involves aggressive treatment and rehabilitation strategies, which halt or slow disease progression, restore function, and limit disability. The categories are used only as a way of organizing a fairly complex body of material and are to some extent not mutually exclusive and overlapping. A number of overarching issues or needs may be identified that cut across these prevention categories and that must be addressed in concert with categorically specific approaches to eliminate disparities: