Case Scenario

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.

Commentary

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

Self-reported race is a complex phenomenon that typically relies on the subjective interpretation of a combination of information, including behavioral, cultural, and societal norms. Cases have been reported of self-identified Black patients who were found to have evidence of European ancestry, and some self-identified White patients who identify as being of European ancestry have evidence of mixed African ancestry.⁹

In reinforcing the false idea of race as a fixed genetic category, the use of race in clinical algorithms may further propagate racism and bias. Critics also argue that the use of race in many widely employed clinical algorithms may exacerbate racial disparities. For example, the use of race correction in the calculation of glomerular filtration rate may systematically underestimate that measurement in Black patients, leading to delayed treatment or decreased likelihood of kidney transplant.¹⁰

Using race as a blunt—and often inaccurate—proxy for genetic ancestry is inadequate, and finding more specific genetic markers for risk of cardiovascular disease (CVD) is an area of ongoing research. CVD is complex; however, it is rarely monogenic. Currently, the use of genetic testing to predict primary cardiovascular events is still investigational and offers little benefit over the evaluation of traditional risk factors, such as those factors included in the ACC/AHA calculator.¹¹