We report several key findings in this analysis of more than 1.9 million weighted young to middle-aged individuals with HF. First, young NH Black adults have twofold higher odds of HF compared with NH White adults of the same age. Second, despite this excess risk, NH Black adults with HF tend to have a similar prevalence of clinically relevant comorbidities compared with White adults and Hispanic adults with HF. Third, mortality across all racial groups was low and no significant difference in all-cause mortality or cardiac mortality was observed between the different racial groups.

Our results are consistent with a 1985–2005 analysis from the Coronary Artery Risk Development in Young Adults (CARDIA) study showing a substantially higher risk of HF among young Black compared to young White adults and expands on this analysis by showing a continuation of this trend for the period of 2005–2018. ⁸ While prior studies have consistently shown a higher prevalence of hypertension among Black adults compared with White adults, ¹¹ which has been considered a major driver of the increased risk of HF among Black adults of all ages, ⁷ our study only showed a marginally higher prevalence of hypertension in Black adults with HF. The available data cannot determine the reason for these differences but may be related to underdiagnosis, greater severity, or effect modification due to exposures related to social determinants of health. ¹² It is important to note that both systolic and diastolic blood pressures measured during the examination were significantly higher in NH Black adults compared to other races/ethnicities supporting prior research on the relationship between higher blood pressures and risk of HF among NH Black adults. ¹²

A higher prevalence of HF among Black individuals may be explained by differences in clinical comorbidities and inherent differences in social determinants of health. ⁷ Although our study showed minimal differences in the prevalence of relevant comorbidities between different races and ethnicities, Black individuals are known to have a higher prevalence of modifiable risk factors like hypertension, obesity, and chronic kidney disease that occur at an earlier age than other races and ethnicities, which likely predisposes them to developing HF at an earlier age.^8,13,14 Disproportionate lack of accessibility and affordability due to socioeconomic constraints precludes Black individuals from receiving optimal care for the management of these chronic conditions. ⁷ There is also a lower inclination toward a healthy lifestyle behavior among Black individuals, as only 20% were reported to have five cardiovascular health metrics at optimal levels, which is lower compared to both White and Hispanic individuals. ¹⁵

All-cause and cardiac-related death rates were not different among all races. In contrast to our analysis, previous studies have shown low short-term and long-term mortality in Black patients after HF hospitalization as compared to White patients.^{16bibr17-17539447241239814–18} However, findings for mortality from our study need to be interpreted with caution as these data were self-reported, the severity of HF was unknown, and event rates for both all-cause and cardiac-related mortality were low across all racial groups due to young age. Other limitations of this study include its retrospective observational nature, and not accounting for unmeasured confounding factors that may have influenced our findings. Moreover, in addition to using objective parameters in establishing the status of some variables, such as the use of hemoglobin A1c in establishing diabetes status and recorded BP in establishing hypertension status, self-reporting was also used in establishing the status of these variables, which could have led to over- or underestimation of true prevalence. HF was not classified into HF with reduced or preserved ejection fraction, which would have provided epidemiological insight into the phenotypic differences across races and ethnicities.