Psychosocial Stressors and Heart Failure Risk Among Black Women in the US

Black women are disproportionately susceptible to developing heart failure and display more severe morbidity and mortality compared with White women. Factors contributing to excess heart failure risk among Black women remain incompletely understood.

To characterize the associations of components of psychosocial stress, including experiences of interpersonal racism and childhood or adolescent abuse, with heart failure development among Black women.

This was a prospective cohort study with baseline assessment in 1997 for racism and 2005 for abuse variables and median follow-up of 24 years (IQR, 16-24 years), ending in 2023. The cohort included Black Women's Health Study participants who were free from heart failure at baseline. Participants resided across all geographic regions of the US.

Participants completed questionnaires on perceived interpersonal racism, including questions on everyday interactions and perceived discrimination in employment, housing, or with police. Self-reported type and frequency of childhood or adolescent abuse were also ascertained.

Incident heart failure, ascertained via questionnaire. Cox proportional hazards regression was used to assess prospective associations of psychosocial stress exposures with incident heart failure.

Among 48 320 Black women (median age at baseline, 40 years [IQR, 32-48 years]; median baseline body mass index [BMI], 27 [IQR, 24-32]), 1343 heart failure events were observed. Perceived discrimination in employment, housing, or interactions with police was associated with increased heart failure risk, with the highest risk observed in the 11% of participants who experienced discrimination in all 3 domains (hazard ratio [HR], 1.27 [95% CI, 1.06-1.52] in multivariate models). The HR for highest (vs lowest) quartile of daily racism score was 1.23 (95% CI, 1.05-1.45) in age-adjusted analyses but was attenuated to 1.04 (95% CI, 0.88-1.22) after adjustment for clinical risk factors. Frequent childhood (HR, 1.54; 95% CI, 1.16-2.06) or adolescent (HR, 1.86; 95% CI, 1.34-2.58) sexual assault (≥4 times) was associated with elevated heart failure risk, with some attenuation after multivariable adjustment, although adolescent abuse remained significant (HR, 1.44; 95% CI, 1.04-2.00). In mediation analysis, BMI was observed to be a partial mediator (proportion mediated, 19.6%-35.9%) of the associations of childhood or adolescent sexual abuse (≥4 times) with incident heart failure.

In this cohort study of US Black women, perceived interpersonal racism and sexual abuse in childhood or adolescence were associated with increased heart failure risk decades later; as these exposures are more prevalent among Black than White women, they may represent risk factors that contribute to heart failure disparities. Future studies are needed to elucidate mechanisms linking psychosocial stress to heart failure, such as changes in BMI.