REasons for Geographic And Racial Differences in Stroke-Myocardial Infarction-4 (REGARDS-MI-4)

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Black-White coronary heart disease (CHD) and heart failure (HF) disparities persist in the US despite decades of research and national public health campaigns. The role of social determinants of health (SDH) like structural racism in health disparities has been studied in only 1% of published work. Few studies of SDH have taken a life course perspective related to risk of CHD and HF. The ability to recover after the stress of an acute health event, or resilience, is an important patient-centered outcome, but the influence of SDH on resilience is unknown. Few past studies have examined both structural and intermediary SDH in the World Health Organization's (WHO) Commission on SDH (WHOCSD) conceptual framework in a longitudinal national sample with rigorously adjudicated CHD and HF endpoints, which is one of the aims of this application. We propose a series of studies to fill these gaps, while also providing rigorously adjudicated CHD and HF events and causes of death to a host of investigators interested in using these data (to date, over 500 have used these data). We build on a track record of mentoring to propose a formal year-long career development program for early-stage investigators (ESI), especially underrepresented minorities (URM). The specific aims of this application are to: (Aim 1) conduct studies examining underlying mechanisms of health disparities, guided by the WHOCSD conceptual framework, in three thematic areas: a) the incidence and recurrence of CHD; b) the incidence and recurrence of HF with preserved ejection fraction and HF with reduced ejection fraction; c) reserve and resilience after an incident or recurrent CHD or HF event. (Aim 2) To continue to adjudicate CHD events, HF hospitalizations, and causes of death to support a wide range of studies by investigators beyond our group, and to link the cohort with Medicare data to support investigators conducting health services utilization studies. (Aim 3) To support the development of researchers in CVD health equity, especially URMs, through a new mentored research program for a cohort of early stage investigators, including analytic and statistical support and an annual 2-day Health Equity Research Summer Institute of presentations, training, mock study section, and networking. Early stage investigators will graduate with specific competencies in CVD health equity research. The proposed grant will inform policy, advocacy, and the design of interventions by generating new evidence on which SDH and disparities in health services lead to population-level disparities in incident and recurrent CHD and HF, and on resilience in recovery after a CHD or HF event. Our multidisciplinary team includes epidemiologists, sociologists, health services researchers, biostatisticians, clinicians, and a participant Advisory Board, assuring rigor and relevance of the proposed research. Continued funding for the REGARDS-MI infrastructure will support a host of additional studies led by an expanding group of investigators. Funding will also expand the cadre of researchers dedicated to discovering strategies to achieve health equity for all US adults, a goal supported by NHLBI, the National Academy of Sciences, the CDC, the American Heart Association, and all major professional societies in the US.