Delivering Ethnic and Racial Diversity in Cardiac Imaging Studies of COVID-19 Patients.

Kim et al. (1) should be commended for undertaking the largest detailed echocardiographic study to date of patients hospitalized with COVID-19. In only a short period, the authors assimilated data on 510 patients, confirming the independent prognostic use of adverse right-ventricular (RV) remodeling. It was disappointing, however, not to see information provided on ethnicity; a potential opportunity to assess the effect of race on the observed echocardiographic abnormalities was missed.

The approximately 2-fold increased mortality risk associated with RV dysfunction mirrors findings from our own report (2). In a UK multicenter study of 164 patients hospitalized with COVID-19, we found no differences between Black and South Asian people compared with White patients in measures of adverse RV remodeling, serum biomarkers of myocardial injury, and fibrin turnover or mortality. The study was limited, however, by its modest size, and the “negative” result may reflect selection bias; the White group was older, more often male, and more likely to smoke than the minority group.

To our knowledge, there are no other cardiac imaging data among minority populations that investigate differences in myocardial response under stress. There are data indicating smaller ventricular volumes in South Asian populations, but the larger echocardiographic registries have focused on the left ventricle rather than the RV at rest (3). Despite the disproportionately high rates of COVID-19 infection, hospitalization, and death in racial and ethnic minority groups (4), it remains unclear as to which genetic or biologic host factors might drive this association.

A call has been made for COVID-19 clinical trials to promote diversity by prioritizing inclusion of minority populations, and the National Institutes of Health-defined phase 3 clinical trials are now required to report outcomes stratified according to race and ethnicity. The same approach must be upheld for observational research; the international cardiac imaging community has a moral and ethical responsibility to play its part.