Using Race with Caution in the ASCVD Calculator
Am Fam Physician. 2021 Sep ;104(2):292-294.
A 58-year-old man, J.D., with a history of hypertension and tobacco use comes to my office to discuss his laboratory results. J.D. had a lipid panel drawn before the visit and wants to know whether he has high cholesterol. I use the American College of Cardiology/American Heart Association (ACC/AHA) 2013 atherosclerotic cardiovascular disease (ASCVD) risk estimator to evaluate the appropriateness of statin therapy in this patient.1 Based on the calculator's components for race, I ask J.D. whether he identifies as African American, White, or Other.
J.D. is confused by the categories offered and responds that he is Puerto Rican. The patient adds, “I have relatives who are Black, and I have relatives who are Spanish.” J.D. wants to know why the clinical calculator does not include multiracial people and why race is relevant to cardiovascular health.
The use of race in clinical decision-making is a source of controversy in U.S. modern medicine. Definitions of race are inconsistent throughout the medical literature and in medical education, and most experts in biology and social sciences agree that race has a limited biologic basis and is actually a social concept influenced by culture and politics, not genetics.2,3
However, the use of race as a descriptor persists in clinical algorithms designed to aid decision-making in patient care.4 Race is used as a variable in clinical calculators in a variety of many specialties, ranging from predictors of in-hospital heart failure mortality to the likelihood of success of a vaginal birth after a previous cesarean delivery.5,6
The reasons for inclusion of race as a variable in clinical calculators are complex. The designers of the 2013 ACC/AHA calculator described in this case used data from several community-based cohorts that included adults identified as African American or White with at least 12 years of follow-up. Data from other racial and ethnic groups were insufficient, which is why they are not included in the final calculator.1
Using calculators that force physicians to place their patients into one of several non-overlapping racial categories can significantly change clinical management. For example, if the patient in the case scenario is categorized as White, the 10-year ASCVD risk is estimated as 5.8%; if the patient is categorized as Other, it is 9.6%. If the patient is categorized as African American, the ASCVD risk jumps to 17.7%.1
It is unlikely that a professional consensus about the role of race in clinical algorithms will occur in the immediate future. It is also unlikely that researchers can immediately develop acceptable replacements for every algorithm that includes race. Therefore, because many of these calculators remain helpful to physicians, a framework for addressing these complex issues with patients is provided.
Consider Race with Caution
Physicians are encouraged to exercise caution when using race as a marker of genetic ancestry because no meaningful relationship may exist between the two categories. See the editorial in a previous issue of American Family Physician that addressed the dangers of practicing race-based medicine.7 Table 1 provides recommendations for terminology on discussing race with patients.8
Recommended Terminology for Discussing Race with Patients
Use granular ethnicity or ancestry to discuss genetic predisposition to disease
Use country of origin
Avoid using imprecise language to approximate ancestry
Avoid terms such as Asian or African American
When discussing unequal medical treatment or unequal burden of disease attributable to racism, choose terms that combine race/ethnicity
Use categories that reflect societal norms for defining populations (e.g., Black or African American, Hispanic or Latino)
Avoid the use of outdated terms that do not reflect current societal norms when defining approximate ancestry
Avoid terms such as Caucasian
Note: The term African American is used when describing the components of the atherosclerotic
Referencesshow all references
1. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;129(25 suppl):S74–S75]. Circulation. 2014;129(25 suppl 2):S49–S73....
2. Yudell M, Roberts D, DeSalle R, et al. Taking race out of human genetics. Science. 2016;351(6273):564–565.
3. Roberts D. Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-First Century. 2nd ed. The New Press; 2012.
4. Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight—reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874–882.
5. Peterson PN, Rumsfeld JS, Liang L, et al.; American Heart Association Get with the Guidelines–Heart Failure Program. A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association Get with the Guidelines Program. Circ Cardiovasc Qual Outcomes. 2010;3(1):25–32.
6. Grobman WA, Lai Y, Landon MB, et al.; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Development of a nomogram for prediction of vaginal birth after cesarean delivery. Obstet Gynecol. 2007;109(4):806–812.
7. Reddick B. Fallacies and dangers of practicing race-based medicine. Am Fam Physician. 2021;104(2):122–123. Accessed August 12, 2021. https://www.aafp.org/afp/2021/0800/p122.html
8. Amutah C, Greenidge K, Mante A, et al. Misrepresenting race—the role of medical schools in propagating physician bias. N Engl J Med. 2021;384(9):872–878.
9. Shriver MD, Parra EJ, Dios S, et al. Skin pigmentation, biogeographical ancestry and admixture mapping. Hum Genet. 2003;112(4):387–399.
10. Levey AS, Titan SM, Powe NR, et al. Kidney disease, race, and GFR estimation. Clin J Am Soc Nephrol. 2020;15(8):1203–1212.
11. Veljkovic N, Zaric B, Djuric I, et al. Genetic markers for coronary artery disease. Medicina (Kaunas). 2018;54(3):36.
12. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019;139(25):e1178–e1181]. Circulation. 2019;139(25):e1046–e1081.
13. Kullo IJ, Trejo-Gutierrez JF, Lopez-Jimenez F, et al. A perspective on the new American College of Cardiology/American Heart Association guidelines for cardiovascular risk assessment. Mayo Clin Proc. 2014;89(9):1244–1256.
14. U.S. Preventive Services Task Force. Cardiovascular disease: risk assessment with nontraditional risk factors. July 10, 2018. Accessed July 14, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/cardiovascular-disease-screening-using-nontraditional-risk-assessment
15. Krist AH, Davidson KW, Mangione CM, et al. Screening for asymptomatic carotid artery stenosis: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(5):476–481.
16. Goff DC Jr, Lloyd-Jones DM. The pooled cohort risk equations—black risk matters. JAMA Cardiol. 2016;1(1):12–14.
17. Krieger N, Waterman PD, Kosheleva A, et al. Racial discrimination & cardiovascular disease risk: My Body My Story study of 1005 US-born black and white community health center participants (US). PLoS One. 2013;8(10):e77174.
18. Kramer MR, Hogue CJ, Dunlop AL, et al. Preconceptional stress and racial disparities in preterm birth: an overview. Acta Obstet Gynecol Scand. 2011;90(12):1307–1316.
19. Palacio A, Mansi R, Seo D, et al. Social determinants of health score: does it help identify those at higher cardiovascular risk? Am J Manag Care. 2020;26(10):e312–e318.
20. Havranek EP, Mujahid MS, Barr DA, et al.; American Heart Association Council on Quality of Care and Outcomes Research; Council on Epidemiology and Prevention; Council on Cardiovascular and Stroke Nursing; Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132(9):873–898.
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to firstname.lastname@example.org. Materials are edited to retain confidentiality.
This series is coordinated by Caroline Wellbery, MD, associate deputy editor.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
Please send scenarios to Caroline Wellbery, MD, at email@example.com. Materials are edited to retain confidentiality.
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