I am and always will be a catalyst for change.¹

—Shirley Chisholm

In 1968—the same year when Martin Luther King, Jr., was assassinated—the tenacious Shirley Chisholm would become the first Black woman to obtain a seat in the US Congress.¹ From her humble beginnings growing up in Brooklyn, NY, as the child of immigrants, she saw problems as possibilities and set out to change them. Shortly after her election to Congress, she would introduce 50 pieces of legislation and emerge as a champion for racial and gender equality, socioeconomic justice and more. Then, just 4 years later, she would set her sights even higher and enter the race for the President of the United States—a previously unthinkable idea for a woman, particularly from a minoritized racial group. The significance of Chisholm and her audaciousness is that it was all rooted in a deep desire for change coupled with a refusal to accept the status quo. Though she faced significant obstacles along the way, she pushed forward, always believing that we could do better and ultimately be better.

Nearly 100 years ago, it was a widely held belief that heart disease was synonymous with bedrest and imminent death. Shortly thereafter, 6 cardiologists founded the American Heart Association (AHA)—all ignited by a belief that through scientific discovery, we could improve outcomes through better understanding, evidence-based treatment, and preventative strategies. Like Shirley Chisholm, these pioneering physicians, social workers, and health care workers in the early days of the AHA were driven by that same idea that we could think big, do more, and effect change.

We have seen improvements in cardiovascular disease (CVD) outcomes since 1924 when the AHA was founded but not equitably. Similar to the racial and socioeconomic gaps noted by Chisholm in her community, those same barriers continue to create imbalances in CVD morbidity and mortality. Though groundbreaking discoveries have been made over the last century, these population-based improvements have not been felt by all demographic groups. Over 2 decades ago, the Institute of Medicine (currently the National Academy of Medicine) produced a report describing the years of systematic unequal treatment of minoritized racial and ethnic groups.² An urgent call for action was made to address discrimination, structural racism, and bias in care.² Yet, there continues to be substantial disparities in the onset of multiple forms of CVD among non-Hispanic Black, Hispanic, non-Hispanic American Indian, Pacific Islander, and South Asian populations compared with non-Hispanic White populations.³ While it is known that these persistent differences in CVD outcomes are multifactorial, their connection to socioeconomic and environmental factors cannot be ignored. Multiple studies have demonstrated that historical redlining—designing a community with the intent to segregate resources from minoritized racial and ethnic groups—has demonstrated a consistently negative impact on the cardiovascular health of non-Hispanic Black patients.^4,5 Failure to address these forms of discrimination will prevent cardiovascular equity. Paul Dudley White, 1 of the 6 founding cardiologists of the AHA, described “a time of almost unbelievable ignorance about heart disease” in those early years.⁶ As policies and ideologies in some parts of the country move away from acknowledging the impact of structural racism, social determinants of health, and bias on inequities in health, there has never been more urgency to embrace these uncomfortable truths.

As a call to action, we encourage AHA partners (patients, community leaders, and clinicians) and scientists to think critically about how to perform cardiovascular equity science, to the end that equity is attainable and lasting.^7,8 This starts with a proper conceptual model or framework, which requires expertise in cardiovascular disparities to understand the layers of the disparities. In addition to critical race theory and the National Institute of Minority Health and Health Disparities Research Framework, consider our Framework Wheel to Address Bias, Social Determinants of Health, and Structural Racism in Cardiovascular Care as an informal guide (Figure). Begin with the inner circle and move outward turning the wheel to align with each goal, which, in some cases, may overlap. Start by identifying who the team stakeholders should include, for example, patients, health care professionals, community members, and scientists, particularly underrepresented groups. While this may seem unusual, this first step may prevent the production of myopic studies that miss important questions relevant to patients and populations that experience disparities. The team can be expanded later based on additional needed expertise. Determine where efforts should align: outpatient, inpatient, or home/community-based locations. Determine what area of CVD will be addressed: prevention (ie, prevention of heart failure or cardiovascular death), treatment (ie, guideline-directed treatment for heart failure), control of risk factors (ie, ideal treatment and dose of heart failure medications), or diagnostic tests (ie, appropriate diagnosis of heart failure). Identify the focus on correcting bias (ie, bias in deciding which types of patients get prevention, treatment, control, or diagnostics), social determinants of health (ie, health literacy preventing appropriate use of a treatment), or structural racism (ie, policies limiting/prohibiting outpatient cardiovascular care to Medicaid beneficiaries who are disproportionately represented by minoritized racial and ethnic groups). Select how you will identify the best strategies: community-based participatory research (research codesigned and implemented by community members and scientists), implementation science (research on strategies to bring evidence-based treatments and tools to the real-world population), and mixed methods (sequential or simultaneous combination of qualitative and quantitative research to understand a problem or process). Strategies for cardiovascular equity may emerge, such as using new technology or risk calculators (particularly artificial intelligence incorporating social determinants of health and mechanisms to address them),⁹ creating financial resources for communities or reallocating resources, changing training, advocating for public policy changes, changing hospital protocols, utilizing media, building a more diverse team, empowering a multidisciplinary team, and other novel ideas. While not included in this model, it is critically important to set metrics for equity designed by the stakeholders, routinely assess for success, and reiterate the strategies as needed to reach equity metrics.

Figure. A framework wheel to address bias, social determinants for health (SDOH), and structural racism in cardiovascular care. The framework wheel is an informal guide to the development of study questions that address key factors promoting cardiovascular care inequity. The circles represent moveable wheels that can be aligned to address bias, SDOH, and structural racism in the delivery of cardiovascular care. Sections between spokes can overlap, and this is not meant to be prescriptive, but rather a starting point. Begin at the center of the wheel and move sequentially to each outer wheel, rotating the wheel clockwise or counterclockwise. Who represents the individuals engaged in performing the research who will identify the topic of importance; where represents the location for the study population; what represents the type of clinical care that requires change; focus represents the focus of the strategies; and how represents scientific methods that may overlap, beyond the dotted line demonstrates examples of potential strategies that may be identified using the scientific methods. Additional strategies may develop while conducting the mixed methods, implementation science, and community-based participatory research studies. EMR indicates electronic medical record; HCP, health care professional; and R/x, pharmaceutical.

At Circulation: Cardiovascular Quality and Outcomes, we are seeking to highlight science that addresses these strategies described in our framework, particularly foundational work developed with community-based participatory research and mixed methods. An example of pivotal qualitative work led by Dr Anika Hines used photovoice to help Black patients with hypertension and chronic kidney disease digitally share, using photographs, how structural racism contributes to their food environment, and how cardiovascular equity might be attained.¹⁰ In work published in Circulation, Dr LaPrincess Brewer used community-based participatory research to understand the reasons for cardiovascular disparities in a faith-based community and together with the community developed a digital application to address risk factors for CVD in Black patients, which statistically improved cardiovascular health status in this population.¹¹ Moving toward cardiovascular-kidney-metabolic disease, in JAMA Internal Medicine, Dr Lilia Cervantes demonstrated that policies allowing only emergency dialysis for undocumented individuals rather than routinely scheduled dialysis were associated with increased mortality¹² and increased cost. Public knowledge of these atrocities contributed to state changes in health care policy, which now cover routine scheduled dialysis among undocumented individuals due to her research.¹³ These studies demonstrate how research may lead to equity.

As we stride into the next century of AHA science, we want to support impactful work that changes cardiovascular disparities and leads to equity. Much of the published works on cardiovascular disparities have focused on epidemiology, which is vitally important to know trends and current practices but is unlikely to lead to equity without an increasing amount of scholarship also focused on strategies to reduce cardiovascular disparities. Cardiovascular implementation science trials and studies specifically designed to address cardiovascular disparities are limited.¹⁴ We recognize that cardiovascular disparities research is more difficult to both publish and receive funding, particularly for minoritized racial and ethnic scientists for whom bias has been well documented.¹⁵ Therefore, it is vital for funding organizations and academia to monetarily invest in the development and sustainment of underrepresented groups from elementary school through senior scientists. The AHA has committed to investing 100 million to address structural racism and health inequity by 2024.¹⁶ Perhaps, the results of these investments will encourage other national funders to follow suit.

The widely broadcasted murders of George Floyd and countless others catalyzed a movement in the United States and elsewhere. Over the past 5 years, many individuals have been made consciously aware of existing social inequalities, secondary to structural racism, and have vocalized a desire to change this system. While enthusiasm has increased to address worsening cardiovascular disparities, it is less clear whether enthusiasm is matched with willingness for discomfort to support systematic changes that may create equity. Consider how research focused on the end point of cardiovascular equity may take the leading steps in societal change. Employ a conceptual model routed in cardiovascular disparities developed by and with experts in cardiovascular disparities.¹⁷ Dare to focus studies on leading contributors of cardiovascular disparities, bias, social determinants of health, and structural racism. Engage in rigorous implementation science, community-based participatory research, and mixed-method studies centered on achieving cardiovascular equity. Here at Circulation: Cardiovascular Quality and Outcomes, we uplift the mission of Chisholm of being a catalyst for change. We welcome and support your pivotal work to restructure our broken health care system.

Dr Breathett receives research funding from the National Heart, Lung, and Blood Institute grants R01HL159216, R56HL159216, R01HL16074, and K01HL142848; the Health Resources and Services Administration of the US Department of Health and Human Services, and the Indiana Clinical and Translational Sciences Institute.

Disclosures Dr Breathett is an associate editor. Disclosures provided by Dr Breathett in compliance with American Heart Asso-ciation’s annual Journal Editor Disclosure Questionnaire are available at https://www.ahajournals.org/pb-assets/policies/COI_02_2023-1675450449580.pdf. Dr Manning is a senior advisor for Circulation: Cardiovascular Quality and Outcomes.

The American Heart Association celebrates its 100^th anniversary in 2024. This article is part of a series across the entire AHA Journal portfolio written by international thought leaders on the past, present, and future of cardiovascular and cerebrovascular research and care. To explore the full Centennial Collection, visit https://www.ahajournals.org/centennial

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

For Sources of Funding and Disclosures, see page 106.

我现在并将永远是变革的催化剂。¹

——雪莉·奇泽姆

1968 年，也就是马丁·路德·金遇刺的同一年，顽强的雪莉·奇泽姆成为第一位在美国国会获得席位的黑人女性。¹作为移民的孩子，她在纽约布鲁克林长大，出身卑微，她将问题视为可能性，并着手改变它们。当选国会议员后不久，她提出了 50 项立法，并成为种族和性别平等、社会经济正义等方面的倡导者。仅仅四年后，她就将自己的目标定得更高，参加了美国总统的竞选——这对于一名女性，尤其是来自少数族裔群体的女性来说，是以前不可想象的想法。奇泽姆和她的大胆行为的意义在于，这一切都源于对变革的强烈渴望以及拒绝接受现状。尽管一路上遇到了重大障碍，但她仍然继续前进，始终相信我们可以做得更好，并最终变得更好。

近 100 年前，人们普遍认为心脏病就是卧床休息和濒临死亡的代名词。此后不久，六位心脏病专家成立了美国心脏协会 (AHA)，他们的信念是：通过科学发现，我们可以通过更好的理解、循证治疗和预防策略来改善结果。与雪莉·奇泽姆 (Shirley Chisholm) 一样，美国心脏协会 (AHA) 早期的这些先驱医生、社会工作者和卫生保健工作者也受到同样的理念的驱动，即我们可以胸怀大志，做得更多，并实现变革。

自 1924 年 AHA 成立以来，我们已经看到心血管疾病 (CVD) 的结果有所改善，但并不公平。与奇泽姆在其社区中指出的种族和社会经济差距类似，这些障碍继续造成心血管疾病发病率和死亡率的不平衡。尽管上个世纪取得了突破性的发现，但并非所有人口群体都感受到了这些基于人口的改善。二十多年前，美国医学研究所（现为美国国家医学院）发表了一份报告，描述了多年来少数种族和族裔群体遭受系统性不平等待遇的情况。²紧急呼吁采取行动解决歧视、结构性种族主义和护理偏见问题。²然而，与非西班牙裔白人群体相比，非西班牙裔黑人、西班牙裔、非西班牙裔美洲印第安人、太平洋岛民和南亚裔人群中多种形式 CVD 的发病率仍然存在巨大差异。³虽然众所周知，CVD 结果的这些持续差异是多因素造成的，但它们与社会经济和环境因素的联系也不容忽视。多项研究表明，历史红线——设计一个旨在将资源与少数种族和族裔群体隔离的社区——已证明对非西班牙裔黑人患者的心血管健康持续产生负面影响。^4,5不解决这些形式的歧视将妨碍心血管公平。美国心脏协会 (AHA) 六位创始心脏病专家之一的保罗·达德利·怀特 (Paul Dudley White) 描述了早年“对心脏病几乎令人难以置信的无知时期”。⁶随着该国某些地区的政策和意识形态不再承认结构性种族主义、健康问题社会决定因素以及健康不平等偏见的影响，接受这些令人不安的事实变得前所未有的紧迫。

作为行动呼吁，我们鼓励 AHA 合作伙伴（患者、社区领袖和临床医生）和科学家批判性地思考如何进行心血管公平科学，以实现公平并持久。^7,8这首先需要一个适当的概念模型或框架，这需要心血管差异方面的专业知识来理解差异的各个层次。除了批判种族理论和国家少数民族健康与健康差异研究框架之外，还可以考虑我们的框架轮来解决心血管护理中的偏见、健康的社会决定因素和结构性种族主义作为非正式指南（图）。从内圈开始，向外转动轮子以与每个目标对齐，在某些情况下，这些目标可能会重叠。首先确定团队利益相关者应包括哪些人，例如患者、医疗保健专业人员、社区成员和科学家，特别是代表性不足的群体。虽然这看起来很不寻常，但这第一步可能会阻止短视研究的产生，这些研究会遗漏与经历差异的患者和人群相关的重要问题。稍后可以根据所需的额外专业知识来扩展该团队。确定应在何处协调工作：门诊、住院或家庭/社区地点。确定将解决CVD的哪个领域：预防（即预防心力衰竭或心血管死亡）、治疗（即指南指导的心力衰竭治疗）、控制危险因素（即心力衰竭药物的理想治疗和剂量） ），或诊断测试（即心力衰竭的适当诊断）。确定纠正偏见（即决定哪些类型的患者接受预防、治疗、控制或诊断的偏见）、健康的社会决定因素（即阻碍适当使用治疗的健康素养）或结构性种族主义（即，限制/禁止向医疗补助受益人提供门诊心血管护理的政策，这些受益人中少数族裔和族裔群体所占比例过高）。选择如何确定最佳策略：基于社区的参与性研究（由社区成员和科学家共同设计和实施的研究）、实施科学（研究将循证治疗和工具带给现实世界人群的策略）以及混合研究方法（定性和定量研究的顺序或同时组合以了解问题或过程）。心血管公平的策略可能会出现，例如使用新技术或风险计算器（特别是纳入健康问题社会决定因素和解决这些问题的机制的人工智能），⁹为社区创造财政资源或重新分配资源、改变培训、倡导公共政策变化、改变医院协议、利用媒体、建立更加多元化的团队、增强多学科团队的能力以及其他新颖的想法。虽然未包含在此模型中，但至关重要的是，设置利益相关者设计的公平指标，定期评估成功情况，并根据需要重申达到公平指标所需的策略。

数字。 解决心血管护理中的偏见、健康社会决定因素 (SDOH) 和结构性种族主义的框架轮。框架轮是制定研究问题的非正式指南，解决促进心血管护理不平等的关键因素。这些圆圈代表可移动的轮子，可以对齐以解决心血管护理中的偏见、SDOH 和结构性种族主义问题。辐条之间的部分可以重叠，这并不意味着是规定性的，而是一个起点。从轮子的中心开始，依次移动到每个外轮，顺时针或逆时针旋转轮子。谁代表从事研究的个人，谁将确定重要的主题；其中代表研究人群的位置；什么代表需要改变的临床护理类型；focus 代表策略的重点；以及如何表示可能重叠、超出虚线的科学方法，展示了可以使用科学方法识别的潜在策略的示例。在进行混合方法、实施科学和基于社区的参与性研究时，可能会制定其他策略。EMR表示电子病历；HCP，医疗保健专业人员；和 R/x，制药。

在《循环：心血管质量和结果》中，我们寻求强调解决我们框架中描述的这些策略的科学，特别是通过基于社区的参与性研究和混合方法开发的基础工作。Anika Hines 博士领导的关键定性工作的一个例子是，利用照片语音帮助患有高血压和慢性肾病的黑人患者通过照片以数字方式分享结构性种族主义如何影响他们的饮食环境，以及如何实现心血管公平。¹⁰在《Circulation》杂志上发表的论文中，LaPrincess Brewer 博士利用基于社区的参与性研究来了解基于信仰的社区中心血管差异的原因，并与社区一起开发了一个数字应用程序来解决黑人患者 CVD 的危险因素，从统计数据来看，改善该人群的心血管健康状况。¹¹转向心血管-肾脏-代谢疾病，莉莉亚·塞万提斯 (Lilia Cervantes) 博士在《美国医学会杂志内科学》杂志上证明，只允许无证个人进行紧急透析而不是常规安排透析的政策与死亡率增加¹²和费用增加有关。公众对这些暴行的了解促成了国家医疗保健政策的变化，由于她的研究，该政策现在涵盖了无证个人的常规定期透析。¹³这些研究展示了研究如何带来公平。

当我们迈入 AHA 科学的下一个世纪时，我们希望支持有影响力的工作，改变心血管差异并实现公平。许多已发表的关于心血管差异的著作都集中在流行病学上，这对于了解趋势和当前实践至关重要，但如果没有越来越多的学术也关注减少心血管差异的策略，就不可能实现公平。专门为解决心血管差异而设计的心血管实施科学试验和研究是有限的。¹⁴我们认识到，心血管差异研究的发表和获得资助都更加困难，特别是对于少数种族和民族科学家来说，他们的偏见已得到充分记录。¹⁵因此，资助组织和学术界必须对从小学到高级科学家的代表性不足群体的发展和维持进行资金投资。AHA 承诺到 2024 年投资 1 亿美元来解决结构性种族主义和健康不平等问题^。16也许这些投资的结果将鼓励其他国家资助者效仿。

乔治·弗洛伊德和无数其他人的谋杀案被广泛报道，引发了美国和其他地方的一场运动。在过去的五年里，许多人已经意识到现存的社会不平等（次要的结构性种族主义），并表达了改变这一制度的愿望。尽管人们对解决日益恶化的心血管差异的热情有所增加，但尚不清楚这种热情是否与支持可能创造公平的系统性变革的不适意愿相匹配。考虑一下以心血管公平为终点的研究如何在社会变革中发挥主导作用。采用由心血管差异专家开发并与心血管差异专家共同开发的心血管差异概念模型。¹⁷敢于将研究重点放在心血管差异、偏见、健康社会决定因素和结构性种族主义的主要影响因素上。参与严格的实施科学、基于社区的参与性研究以及以实现心血管公平为中心的混合方法研究。在《循环：心血管质量和结果》中，我们提升了 Chisholm 成为变革催化剂的使命。我们欢迎并支持您为重组我们破碎的医疗保健系统所做的关键工作。

Breathett 博士获得国家心肺血液研究所的研究资助 R01HL159216、R56HL159216、R01HL16074 和 K01HL142848；美国卫生与公众服务部卫生资源与服务管理局以及印第安纳临床与转化科学研究所。

披露布雷塞特博士是副主编。Breathett 博士根据美国心脏协会年度期刊编辑披露调查问卷提供的披露内容可参见 https://www.ahajournals.org/pb-assets/policies/COI_02_2023-1675450449580.pdf。曼宁博士是循环：心血管质量和结果的高级顾问。

美国心脏协会将于 2024 年庆祝成立 100 周年。^本文是国际思想领袖撰写的整个 AHA 期刊系列文章的一部分，内容涉及心脑血管研究和护理的过去、现在和未来。要探索完整的百年纪念收藏，请访问 https://www.ahajournals.org/centennial

本文表达的观点不一定代表编辑或美国心脏协会的观点。

有关资金来源和披露信息，请参阅第 106 页。