Cardiovascular Health Equity: Time for a New Era of Science, Sociology, and Interventions

State of the Art: An Untenable Paradox

The story of cardiovascular medicine is one of extraordinary progress. Remarkable breakthroughs in cardiovascular science and compelling clinical trial data now offer markedly improved outcomes for patients with cardiovascular disease (CVD). Correspondingly, deaths caused by CVD, while still the leading cause of overall mortality, are 50% less over recent decades (1). Moreover, the arsenal for CVD prevention and the mitigation of risk represents a robustly populated and decidedly efficacious armamentarium. On the precipice of discovery and implementation are gene therapy, new biological therapies (eg, therapeutic nucleic acids, gene editing, incretin therapies, and myosin modulators), and the still untapped potential of artificial intelligence and precision medicine in CV care.

Yet, this remarkable progress conceals a persistent and troubling truth: not everyone has benefited fairly. Health inequities as defined by the World Health Organization remain an existential challenge in cardiovascular medicine. Despite the scientific triumphs of our field, life expectancy and CVD mortality vary profoundly by geography, race, sex, socioeconomic status, and access to care. Globally, CVD remains the leading cause of death, responsible for 20.5 million deaths annually, with more than 80% occurring in low- and middle-income countries (LMICs) and one-third occurring prematurely. Even within high-income nations, marginalized populations, including rural communities, continue to experience disproportionate disease burden and poorer outcomes akin to outcomes in LMICs.

This paradox is no longer tenable and demands a new and different response—one grounded in science. It calls for moving beyond description to action, beyond recognizing inequities to elucidating biology, and beyond rhetorical statements to evidence-based interventions that can meaningfully close the gap. Health equity should be viewed not as a politicized agenda but as a scientific frontier (like any other) in cardiovascular medicine. And, as such, health equity merits consideration as an emerging discipline that integrates data science, translational research, and implementation strategies offering novel solutions with the potential to measurably close the gap.

The Persistent Burden of Inequity

Within the United States, multiple populations experience CVD health inequities by race, ethnicity, rurality, disability, LGBTQIA+, lower literacy levels, and lower socioeconomic status. In the aggregate, nearly 50% of the U.S. population is at risk for or experience notable CVD inequities (2, 3).

In Europe, recent analyses from the European Society of Cardiology Atlas of Cardiology (4) confirm substantial and persisting cardiovascular inequities across and within countries, with pronounced East-West and North-South gradients in CVD mortality, risk factor prevalence, and access to prevention and specialist care. Socioeconomically deprived communities, migrants, and rural populations experience higher disease burden, underuse of guideline-directed therapy, and greater exposure to environmental stressors such as air pollution, noise, and heat. These inequities contribute to approximately 700,000 excess deaths annually and over 30 million experiencing health inequity, imposing large macroeconomic losses across EU Member States (4, 5). Thus, this burden accounts for 20% of total health care costs, 15% of social services benefits, and an estimated negative economic impact in the EU >9% of total GDP (6).

In the Middle East (and elsewhere), women remain less likely to receive guideline-directed therapy, with worse outcomes—a pattern seen globally.

The global toll is staggering. In LMICs, where access to preventive care, diagnostics, and essential medicines is limited, the probability of dying prematurely from CVD is nearly twice that in high-income nations. Inequities are not only measured in mortality but in lost productivity, economic strain, and social destabilization. The World Bank estimates that the economic cost of noncommunicable diseases, driven largely by CVD, could surpass $47 trillion by 2030—an unsustainable trajectory for global development and a morally unconscionable state of health inequity (6) (Table 1).

Understanding Health Equity and Its Determinants

Health equity is often conflated with equality, but the distinction and separation are critical. Equality assumes identical resources or opportunities; equity recognizes that fairness requires proportional investment to overcome structural and social disadvantages. The World Health Organization emphasizes as absolute prerequisites needed to attain health equity as the “absence of unfair, avoidable, or remediable differences in health.”

In recent years, the understanding of inequity in the United States has centered on the social determinants of health (SDOH). The SDOH are the conditions in which people are born, live, work, and age. Factors such as income, education, housing, environment, and access to care may explain as much as 80% of the variation in cardiovascular outcomes. However, although the SDOH framework remains indispensable, it is both imperfect and incomplete. The more rudimentary univariate Social Determinants of Health model requires more sophisticated assessments, including compilation of various risk indexes (eg, Social Vulnerability Index, Area Deprivation Index), geocoding, geospatial mapping, and environmental exposures (7). For example, U.S.-based geospatial mapping models allow more careful assessment of housing adequacy, rent burden, and air quality all in addition to traditional SDOH and all independently associated with health outcomes (8).

In the European context, health inequity is routinely quantified using disability-adjusted life years, the Slope Index of Inequality, and national deprivation indexes linked to longitudinal registry data (eg, MEDEA Index, German Index of Multiple Deprivation). These indicators enable fine-grained geospatial mapping of cardiovascular outcomes across regions and socioeconomic strata, providing a more policy-relevant framework than single-indicator SDOH models (4, 9).

The decades old and long-standing socioeconomic calibration of European countries (also used in Africa, Asia, and Latin America) using the Gini coefficient, created in 1915, assesses the contribution of social factors worldwide affecting health. Health inequity as described outside of the United States is often measured as disability-adjusted life years and the Slope Inequality Index. That model now potentially benefits from more contemporary and precise discrimination at the extremes of income; yet, more research is necessary (9).

The burden of climate variations worldwide must not submit to prevailing disinclinations prohibiting the study and even challenging the existence of climate change; rather, this scientific truism should be submitted to careful research addressing associations, potentially causative, with CVD. Changes in heat and cold exposure, air pollution (eg, hydrocarbons), water quality (eg, heavy metal contamination), and weather disasters are not without consequence in chronic diseases (10). And, the still uncertain but worrisome association of “forever chemicals,” ie, perfluoroalkyl and polyfluoroalkyl substances, and microplastics with chronic disease requires study and urgently so (11). Moreover, today’s global reality of violence, war, abrupt societal disruption, and forced migration argue for careful investigation assessing impact and CVD outcome.

New Biological Paradigms

Science has afforded notable progress in the study and treatment of CVD and may allow demystifying disparate disease burden and health outcomes. Molecular epidemiology is a discipline of interest and adds to the traditional understanding of disease burden by uploading extant well-characterized cohort studies with epigenetic, genetic, and cellular mechanisms as either risk enhancers or risk mitigators. Ongoing research encompasses epigenetic factors and subsequent changes in DNA methylation and gene transcription as new models of disease burden (12). The emerging focus on the inflammasome holds the potential to identify more root biological causes responsible for both the burden and severity of disease. Exciting new data further our understanding of clonal hematopoiesis of indeterminant potential as both a risk marker and risk factor for CVD. Similarly, clonal hematopoiesis of indeterminant potential may be associated with responses to evidence based cardiovascular care and consequently predict prognosis (13). A long history of genomic investigation now includes careful study of genomic ancestry as a strong variable in disease expression and an arbiter of risk while certain sequence variations are immediately actionable upon discovery. Polygenic risk scoring holds promise as an additional tool inferring risk and CVD (14). The heretofore crude markers of race, ethnicity, and geographical origin may fully yield to the foregoing science allowing much more precise and perhaps clinically actionable biological constructs.

Barriers to Equity in Cardiovascular Care

• Achieving cardiovascular health equity requires confronting multiple interlocking barriers. Access remains foundational regardless of the setting. In high-income settings, underinsurance and fragmented systems perpetuate disparities; in LMICs (and within large at-risk communities embedded in high-income countries), the absence of primary prevention and diagnostic capacity, lack of adequate social services, and the dearth of physicians remain fundamental constraints.

• Bias and culture further impede equity and function independent of new scientific discovery. Implicit bias can negatively influence decision-making, treatment intensity, and patient trust. Gender and racial stereotypes subtly shape both clinician perception and patient engagement. Moreover, care models often fail to account for the lived experiences of the populations served, and language, cultural context, and trust all influence adherence and outcomes. Importantly, there is no reason to believe issues of bias and culture are immutable. Additional study of the social science of health inequity offers potential insight and new opportunity.

• Digital inequity has emerged as the newest barrier. The promise of telehealth and digital diagnostics is tempered by the limited broadband in rural, older, and lower-income populations. The digital transformation of care must therefore be accompanied by digital inclusion strategies, ensuring that innovation reduces, rather than redoubles, inequity.

Implementation Science: Translating Knowledge into Action

Building on new science, the next challenge lies in applying that knowledge to improve outcomes. The true benefit of scientific discovery is the ease of translation into improved health and outcomes. Implementation science provides the framework to close the “knowing–doing gap,” examining how evidence-based interventions can be adapted and scaled across diverse settings.

Several models already demonstrate success. However, implementation at scale remains challenging. Digital tools hold promise in transforming access within resource-limited environments, provided cost, connectivity, and literacy gaps are addressed. Pharmacologic and policy innovations also hold promise. The polypill, championed in global prevention strategies, offers a scalable, cost-effective means of reducing risk in low-resource settings (15). The “Food is Medicine” movement reframes nutrition as a therapeutic intervention, integrating produce prescriptions and medically tailored meals into health systems (16).

Across Europe, multiple implementation exemplars demonstrate scalable equity-oriented cardiovascular prevention, including population salt-reduction strategies (Finland, United Kingdom), primary-care-anchored hypertension programs, and urban-health initiatives integrating active transport, green space, and air quality improvement. These approaches illustrate how clinical prevention can be aligned with social and environmental determinants to narrow cardiovascular inequities (5, 20).

The challenge ahead is aligning innovation with inclusion, investigation with equity, and discovery with diverse ideation. This calls for a new science designed, tested, and deployed with equity in mind, considering context, access, affordability, and cultural resonance. To catalyze such a shift, The Seven Imperatives for a New Era of Health Equity Science (Table 2) provide the essential steps to meaningfully close the gap and establish the blueprint for the next phase of health equity science.

Cardiovascular Health and the Challenge of Health Equity: An Attainable Goal

Advancing health equity is not solely an ethical goal; it is central to the veracity of cardiovascular science, and it is why research matters. Missed opportunities and persistent health inequities do not represent the best of cardiovascular medicine. Although race and ethnicity still matter regarding issues of bias, no longer is it the standard to invoke race and/or ethnicity in descriptions of health disparities or separately in efforts to attain health equity. The emerging science of health equity can illuminate novel biology revealing how stress, environment, and adversity translate into disease, and introduce targeted new interventions translating understanding into measurable improvements in outcomes. Adopting such an equity-centric approach is of paramount priority and is the sine qua non to eliminating health disparities.

This envisioned new era has the potential, unlike any prior moment in cardiovascular science, to redefine prevention, optimize care delivery, and ensure that all patients worldwide, benefit equally from the promise of modern cardiovascular medicine.

Publisher Note

This paper was jointly developed by JAC, Circulation, European Heart Journal, Global Heart and jointly published by Elsevier Inc, Wolters Kluwer, Oxford University Press and World Heart Federation. The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can be used when citing this article.