Racial Disparities in Heart Attack Recovery: Role of Stress and Stigma

描述(由申请人提供)：在急性心肌梗死(AMI)后，老年非裔美国人的功能恢复往往比同龄白人差得多，死亡率也高得多。在对传统上用来解释这种差异的因素进行调整后，老年人心血管结果的种族差异仍然存在，例如社会经济地位和获得医疗保健的机会。我们的总体目标是研究老年人急性心肌梗死康复结果中的种族差异是否部分是由年龄耻辱和种族耻辱的共同影响解释的，这两种影响都会产生压力。 基于我们的先导数据、污名文献和Rutter的累积风险理论，我们将首次检验以下假设：(1)年龄污名越大的非裔美国人和白人的功能恢复越差；(2)年龄污名对功能恢复的有害影响在非裔美国人中比白人更大；(3)在非裔美国人中，(A)年龄污名和种族污名的人功能恢复更差，以及(B)年龄污名和种族污名将协同作用，恶化功能恢复；(4)自主神经系统(ANS)功能障碍将在以下过程中起中介作用：(A)年龄歧视影响非裔美国人和白人的功能恢复；(B)种族污名影响非裔美国人的功能恢复。 这项拟议研究的第二个目的是确定方法，以帮助从急性心肌梗死中恢复的老年人应对年龄耻辱和种族耻辱。我们将把重点放在可能适合未来干预的应对策略上。 使用前瞻性的纵向设计，我们的跨学科团队将在急性心肌梗死后入院一周内评估200名50岁及以上的非裔美国人和200名白人，并在1个月、4个月、8个月和12个月后再次评估他们。功能恢复将通过随时间推移的体能表现进行评估。中介ANS功能障碍将通过24小时心率变异性和对实验室应激源的急性反应来衡量。次要结果包括抑郁、认知功能和不良心血管事件。相关的协变量将被包括在分析中，如年龄、急性心肌梗死严重程度和抑郁。 这项研究是对PA-05-029《健康的社会和文化层面》的回应，因为我们将研究耻辱的社会结构如何影响急性心肌梗死的康复。此外，这项研究符合NHLBI解决健康差距的战略，该战略包括确定促进疾病发展的心理社会机制，这些疾病对少数群体造成了不成比例的影响。这项拟议的研究可能会揭示一种尚未探索的机制，使污名能够恶化健康。此外，它还可以为今后的干预措施奠定基础，以改善一般老年人，特别是非裔美国老年人的急性心肌梗死康复体验。 公共卫生相关性：老年非裔美国人心脏病发作后恢复较差一直是一个公共卫生问题。我们希望展示一个以前从未探索过的心理因素，以及一个身体因素是如何导致非裔美国人和白人复苏之间的差异的。此外，我们的研究可能为未来提高老年人，特别是非裔美国老年人心脏病发作恢复的成本效益程序奠定基础。

DESCRIPTION (provided by applicant): Following an acute myocardial infarction (AMI), older African Americans tend to have significantly worse functional recovery and higher mortality rates than same-aged Whites. Race differences in older individuals' cardiovascular outcomes remain after adjusting for factors that traditionally have been used to explain this disparity, such as socioeconomic status and access to health care. Our overall goal is to examine whether this racial disparity in older individuals' AMI-recovery outcomes is partially explained by the combined influence of age stigma and race stigma, both of which can generate stress. Based on our pilot data, the stigma literature, and Rutter's theory of cumulative risk, we will examine the following hypotheses for the first time: (1) African Americans and Whites with greater age stigma will have worse functional recovery; (2) Age stigma's deleterious influence on functional recovery will be greater among African Americans than Whites; (3) Among African Americans, (a) those with greater age stigma and race stigma will have worse functional recovery, and (b) age stigma and race stigma will act in a synergistic way to worsen functional recovery; and (4) Autonomic nervous system (ANS) dysfunction will mediate the process by which (a) age stigma impacts the functional recovery of African Americans and Whites, and (b) race stigma impacts the functional recovery of African Americans. The secondary aim of the proposed study is to identify methods to help older persons recovering from an AMI cope with age stigma and race stigma. We will focus on coping strategies that may be amenable to future interventions. Using a prospective, longitudinal design, our interdisciplinary team will assess 200 African Americans and 200 Whites, aged 50 and over, within a week of hospital admission following an AMI, and assess them again one month, four months, eight months, and twelve months later. Functional recovery will be assessed by physical performance over time. The mediator, ANS dysfunction, will be measured by 24-hour heart-rate variability and acute response to laboratory stressors. Secondary outcomes consist of depression, cognitive functioning, and adverse cardiovascular events. Relevant covariates will be included in analyses, such as age, AMI severity, and depression. This study is responsive to PA-05-029, Societal and Cultural Dimensions of Health, because we will examine how the societal construct of stigma influences AMI recovery. Additionally, the study fits the NHLBI Strategy for Addressing Health Disparities which includes identifying psychosocial mechanisms that contribute to the progression of diseases that disproportionately affect minorities. The proposed research could illuminate an unexplored mechanism that enable stigmas to worsen health. In addition, it could lay the groundwork for future interventions to improve the AMI-recovery experience of older persons in general and African American older persons in particular. Public Health Relevance: The worse recovery of older African Americans following a heart attack has been a persistent public-health problem. We expect to show how a previously unexplored psychological factor, in combination with a physical factor, contributes to the disparity between African American and White recovery. Further, our research could lay the groundwork for future cost-effective procedures to improve heart attack recovery of older persons in general and African American older persons in particular.