Rethinking Cardiovascular Disease: The Social Determinants of Heart Health, Part 1
The following is part 1 of 3 in a series of articles titled, "The Social Determinants of Heart Health" by Jason Ausili, PharmD, MSLS, Head of Pharmacy Transformation for EnlivenHealth, as well as other contributors to Ask Your Pharmacist.
America’s heart is at risk. If you’re like most Americans (51%, in fact), it might surprise you to learn that heart disease is the leading cause of death in the United States. Not cancer, not COVID-19, not car accidents — heart disease. In fact, heart disease has held the top spot every year for over 100 years, killing one person every 34 seconds.
While traditional medications and lifestyle changes play a crucial role in prevention, a hidden factor often lurks beneath the surface: social determinants of health (SDOH). Access to healthy food, stable housing, and reliable transportation — these seemingly unrelated conditions can significantly impact our heart health. In fact, a recent scholarly article highlights the evidence that SDOH barriers are associated with high blood pressure, inflammation, chronic stress, and excess cholesterol. Challenges of this nature may require patients to make the difficult choice of picking up their heart medications or paying for their next meal.
But this isn't a fight destined to be lost. Enter the unsung heroes on the front line: community pharmacists. Armed with knowledge, compassion, and access to SDOH screening tools, pharmacists — the country’s most accessible healthcare providers — stand poised to rewrite the narrative.
Let’s delve more into cardiovascular disease’s grip on the population and how pharmacists can fight back.
What Does Cardiovascular Disease Encompass?
The latest Heart Disease and Stroke Statistical Update from the American Heart Association reports that nearly half (48.6%) of all people in the U.S. have or are at risk for some type of cardiovascular disease (CVD). But what does that mean? What conditions are included in the term “cardiovascular disease?”
A literal combination of root words meaning “heart” and “vessel,” cardiovascular disease is the umbrella term for a number of conditions that affect the heart and blood vessels. These conditions include, but are not limited to:
Coronary Heart Disease (CHD): A patient with coronary heart disease (CHD) suffers from a buildup of plaque in the arteries of the heart, limiting blood flow and preventing the heart muscle from receiving enough oxygen. This condition can lead to angina (chest pain) and potentially life-threatening events like heart attacks. The term coronary heart disease is often used interchangeably with coronary artery disease (CAD), though CHD is actually a result of CAD.
Stroke: A stroke occurs when blood flow to the brain is disrupted, either by a clot or weakened blood vessels. And while a stroke itself can be terrifying, its aftermath can be devastating. Survivors often face paralysis, speech difficulties, and cognitive impairment, adding a heavy burden to families and already taxed healthcare systems. And those are the ones who survive.
Heart Failure: When a weakened heart struggles to pump effectively, fluid backs up throughout the body. This leads to breathlessness, fatigue, and an all-around decreased quality of life. Heart failure doesn’t mean that the heart stops beating; it still works, but it doesn’t work as effectively as it should, starving the body of the oxygen carried by blood. Affecting millions, this chronic condition demands careful management to prevent further complications.
Cardiac Arrhythmias: When the heart’s rhythm is too slow, too far, or simply irregular, patients can experience palpitations, dizziness, and even fainting. Arrhythmia can affect how well the heart works, handicapping the cardiovascular system and blocking the body from getting the blood it needs to operate. While some arrhythmias are benign, others require immediate medical attention to prevent potentially fatal consequences.
This diverse family of diseases, woven together under the banner of “cardiovascular disease,” casts a long shadow on national health statistics and individual lives.
How Does High Blood Pressure Factor Into CVD?
While high blood pressure is not generally included under the banner of cardiovascular disease, it is one of the highest contributing factors. (This is why many publicly available reports, studies, and articles often list it when discussing cardiovascular disease.)
It is estimated that 122.4 million (about 47%) of U.S. adults have hypertension, or high blood pressure. Often known as the “silent killer,” many people suffering from high blood pressure never experience symptoms and aren’t aware they even have it. But a lack of symptoms doesn’t mean that it isn’t doing harm.
“In terms of your heart, there is a strong link between hypertension and coronary artery disease,” said Kavitha Kalvakuri, MD, a cardiologist at OSF HealthCare Cardiovascular Institute. “Blockages and coronary artery disease development can be accelerated by hypertension. Think of blood pressure as the mountain and the heart as the horse. The higher one is, the harder the other has to work.”
Let’s look at it another way. Imagine your arteries as vital highways transporting blood throughout your body. Now, picture heavy traffic constantly surging through these narrow lanes. That's what happens with high blood pressure, a relentless force silently pushing against artery walls. Over time, this relentless pressure takes its toll, paving the way for cardiovascular disease in several ways:
Arterial Damage: The constant strain weakens and hardens arterial walls, leading to atherosclerosis, a dangerous buildup of plaque that further narrows the passage for blood flow. This sets the stage for heart attacks when a blockage completely cuts off supply, or strokes when a clot dislodges and travels to the brain.
Heart Strain: Imagine your heart as a tireless pump. With high blood pressure, it must work harder to push blood against the increased resistance, leading to thickening of the heart muscle and eventually, heart failure.
Organ Damage: Uncontrolled high blood pressure doesn't discriminate. It can damage vital organs like the kidneys, leading to impaired function and further complications.
The link between high blood pressure and cardiovascular disease is undeniable. It's like a ticking time bomb waiting to explode. But the good news is, early detection and management can dramatically lower the risk. This is where community pharmacists, with their accessibility and expertise, play a crucial role in identifying and addressing this silent killer before it wreaks havoc on our hearts.
Health Equity & Cardiovascular Disease
The stark reality is that the burden of cardiovascular disease falls disproportionately on communities facing health inequities. According to the American Heart Association, certain racial and ethnic minority groups, individuals with lower socioeconomic status, and residents of rural areas experience higher rates of cardiovascular disease and worse cardiovascular health outcomes. This disparity underscores the crucial role of social determinants of health (SDOH) in shaping heart health.
Lack of access to healthy food, safe housing, affordable healthcare, and quality education significantly impact cardiovascular health. Food insecurity fuels unhealthy diets, leading to obesity and diabetes, which are major risk factors for heart disease. Unstable housing creates chronic stress, a potent trigger for high blood pressure. Limited access to healthcare delays diagnoses and treatment, worsening pre-existing conditions. These are just a few examples of how SDOH factors weave a web of vulnerability, increasing the risk of cardiovascular disease for disadvantaged communities.
Community pharmacists are uniquely positioned to play a vital role in bridging the health equity gap. Their accessibility, trusted relationships with patients, and growing focus on SDOH screening empower them to identify and address social factors impacting cardiovascular health within their communities. By advocating for change at individual and systemic levels, community pharmacists can become powerful agents for ensuring everyone has the opportunity for a healthy heart and an equitable chance at a longer, healthier life.
Operationalizing SDOH Screening in Your Pharmacy in 6 Steps
So, you're convinced about the potential of SDOH screening to make a tangible difference in your community's cardiovascular health. But where do you start? Implementing SDOH screening might seem daunting, but rest assured, it's an achievable goal with the right steps:
Assess Your Readiness: Start by evaluating your resources and team. Research available SDOH screening tools (see Step #2) and consider who on your staff could champion this initiative. Training in motivational interviewing and cultural competency would also be valuable assets.
Choose Your Screening Tool: Research and select an SDOH screening tool that aligns with your workflow and patient population. Options range from brief questionnaires to more comprehensive assessments. (For example, a list from the American Academy of Family Physicians’ publication FBM offers both assessments and questionnaires from the National Association of Community Health Centers, the AAFP’s EveryONE Project, and the Centers for Medicare & Medicaid Services.)
Integrate Into Your Workflow: Determine how SDOH screening will be seamlessly incorporated into patient interactions. Consider integrating questions during medication reviews, new patient consultations, or specific disease management programs.
Train Your Team: Ensure your team understands the importance of SDOH screening and how to use the chosen tool effectively. Practice role-playing scenarios to build confidence and maintain confidentiality.
Connect with Local Resources: Research and develop relationships with community organizations that offer services addressing identified SDOH needs. This could include food banks, housing assistance programs, transportation services, and mental health providers.
Track and Iterate: Regularly monitor the impact of your SDOH screening program. Track the number of screenings conducted, referrals made, and patient outcomes. Use this data to refine your approach and identify areas for improvement.
(A recent EnlivenHealth webinar featured experts from the Pennsylvania Pharmacists Care Network and the Nesbitt School of Pharmacy at Wilkes University discussing both the process and the results of an SDOH screening program implemented at Weis Markets. Watch the webinar recording to hear that discussion and find out how technology can drive consistency and efficiency with the screening and referral process.)
Remember, implementing SDOH screening is a journey, not a destination. Start small, build your expertise, and celebrate every step in making a difference for your patients and community. By empowering individuals to address the social factors impacting their health, you're not just dispensing medications — you're opening doors to healthier, happier lives.
The Future of Cardiovascular Disease Treatment
Pharmacists have a crucial role to play in mitigating and even treating cardiovascular disease by addressing the very root causes often missed by conventional healthcare: social determinants of health (SDOH). If we can tap into the untapped potential of SDOH screening and witness the transformative power of pharmacists, we can rediscover the hope that beats within every community.