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

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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.