Left- vs. Right-Sided Heart Failure: Know the Differences

What Does Green, Yellow, Or Brown Phlegm Mean?

Problems in the lungs can cause phlegm to change color. Green or yellow phlegm can occur with an infection, but brown phlegm might indicate bleeding in the lungs.

Phlegm is a type of mucus that comes from the lungs and respiratory tract. Typically, phlegm is clear, thin, and unnoticeable. When someone has a cold or infection, the phlegm can become thickened and change color. Other underlying causes may also affect phlegm color.

This article looks at the various colors that phlegm can be and what these mean for a person's health. It also examines the different textures of phlegm and explains what someone can do if their phlegm changes.

The color of phlegm can offer useful information about what may be happening with the lungs and other organs of the respiratory system. A person can follow this color guide for reference:

Clear

Clear phlegm is typical. It consists of water, salts, antibodies, and other immune system cells. After its production in the respiratory tract, most of it goes down the back of the throat, before a person swallows it.

Brown and black

Brown phlegm may indicate possible bleeding. While it is likely due to bleeding that happened a while ago, it can also indicate a chronic infection such as bronchiectasis. People living with cystic fibrosis may have brown phlegm, and individuals who smoke may also have brown phlegm.

Black phlegm may indicate the presence of a fungal infection, a history of smoking, or other substances that a person has inhaled regularly.

Someone who has black phlegm should contact their doctor immediately, especially if they have a weakened immune system.

White

White phlegm signifies nasal congestion. When the nasal cavity is congested, the tissues are swollen and inflamed, which slows the passage of phlegm through the respiratory tract. When this happens, the phlegm becomes thicker and cloudy or white. As such, white phlegm may occur due to allergies, asthma and often viral infections

Yellow

Yellow phlegm suggests that immune cells are starting to work at the site of the infection or another type of inflammatory condition.

White blood cells are the cells of the immune system that are responsible for fighting germs. As they continue to fight the infection, the phlegm picks them up, giving it a yellowish tinge.

Green

Green phlegm indicates a widespread and robust immune response. The white blood cells, germs, and other cells and proteins that the body produces during the immune response give the phlegm its green color.

While phlegm of this color can point to an infection, a person does not always need antibiotics. Most infections that lead to green phlegm are viral and usually resolve without treatment within a few weeks.

The phlegm often changes back to white after a few days. If this does not occur over a prolonged time, this may indicate a bacterial infection.

A person should consult with their doctor before using antibiotics. Using antibiotics when they are unnecessary can be harmful, as bacteria can build up resistance. If green phlegm occurs with breathing difficulties, chest pain, or coughing up blood, this is another sign to consult a doctor urgently.

Red

Red phlegm signals the presence of blood. Doctors may refer to coughing up blood as hemoptysis. There are many reasons for blood in the phlegm.

A lot of coughing, such as with a respiratory infection, can sometimes cause small blood vessels in the lungs or airways to break and bleed.

When there is swelling in a person's nasal passage, they can get a nosebleed. This can cause blood to seep into postnasal drip that they then cough out.

In other situations, blood in the mucus can indicate the presence of a serious medical condition such as tuberculosis, an abscess, or lung cancer.

Read on to learn more about blood in phlegm.

Phlegm can also take on different textures, ranging from watery to thick and tacky. Thin and watery phlegm is usually typical and indicates a healthy respiratory tract.

During an infection, immune cells, germs, and debris build up in the phlegm, making it thicker, stickier, and cloudier.

Coughing and sneezing help the body clear out the excess phlegm, mucus, and other things that do not belong in the respiratory tract.

Illness or infection are not the only things that can cause phlegm to become thicker. Being dehydrated or even sleeping can cause the phlegm to move slower and become thicker than usual.

Pink and frothy phlegm can mean that someone is experiencing heart failure, especially when it occurs with any of the following symptoms:

shortness of breath

sweating

chest pain

Anyone experiencing these symptoms should visit the emergency room immediately.

In addition, frothy phlegm can occur due to altitude sickness and acute respiratory distress syndrome.

It is important to note that doctors cannot diagnose a particular disease or condition according to the color of a person's phlegm.

Having green, yellow, or thickened phlegm does not always indicate the presence of an infection. And if there is an infection, the color of the phlegm does not determine whether a virus, bacterium, or pathogen has caused it. Simple allergies can also cause changes in the color of the mucus.

Antibiotics will not always resolve green mucus.

People who have white, yellow, or green mucus that is present for more than a few days, or if they experience other symptoms, such as fever, chills, a cough, or sinus pain, should speak with a doctor. However, a person is usually fine to wait a few days to try and treat the symptoms at home before making an appointment.

Someone who develops new or increased red, brown, black, or frothy sputum should call their doctor for an appointment immediately. These symptoms can be signs of a more serious medical condition that requires prompt treatment.

White, yellow, or green phlegm is usually treatable at home.

People should try to get lots of rest and stay hydrated. Dehydration can worsen thick phlegm, making it harder to cough up. Some individuals may find that gentle walking can help them cough up the excess phlegm.

Some other measures to try at home include using the following:

Humidifier

Running a humidifier can help moisten the air, which eases breathing, making it easier to cough and loosen up the phlegm stuck in the chest.

Expectorants

OTC expectorants, such as guaifenesin, help thin the mucus, making it easier to cough up.

Expectorants are available for both children and adults at the local pharmacy. It is important to read the directions and take the medication exactly as the label or pharmacist instructs.

Saltwater

Gargling with salt water or using a saline solution to clear out the nasal passages is a common way to help clear out phlegm during a viral or bacterial infection.

For gargling, a person can dissolve a one-quarter teaspoon of salt in a cup of warm water. For clearing out the nasal passage, they can purchase a nasal spray or use a neti pot to rinse the nose.

Read on to learn more about home remedies for clearing phlegm.

In most cases, home care measures are safe and effective ways to deal with atypical phlegm.

It is important to call a doctor if the phlegm does not improve after a few days. An antibiotic may be necessary to treat an underlying bacterial infection.

Anyone with pink, red, brown, black, or frothy mucus should contact their doctor or go to the local emergency room for an evaluation.

Here are some common questions and answers regarding phlegm.

What is the difference between mucus and phlegm?

Different areas of the body, including the upper respiratory tract — which includes the nose, mouth, and throat — and gastrointestinal tract secrete mucus.

But phlegm refers to mucus that the lungs specifically produce. Another term for phlegm is sputum. So when a person coughs out mucus, people refer to it as phlegm, but not the mucus that the nose produces.

Is snot the same as phlegm?

Snot refers to nasal mucus, so it is not phlegm or sputum, which comes from the lungs.

What is the difference between phlegm from allergies and phlegm from a cold?

Allergy-related phlegm will tend to be clear. Colds or infections will usually cause green or yellow phlegm.

What do different colors of phlegm mean?

Different colors of phlegm can indicate different health conditions. White phlegm usually means nasal congestion, while yellow or green phlegm can indicate an infection. A person with cystic fibrosis may have brown phlegm, while black phlegm may suggest a fungal infection. Red phlegm can indicate the presence of blood.

What kind of phlegm should I worry about?

A person should seek immediate medical attention if they have red, black, or brown phlegm, as they can indicate the presence of blood or a potentially serious infection. If a person consistently experiences other colors of phlegm, it is important to contact a doctor for advice on suitable treatments.

What kind of phlegm is infection?

Yellow or green phlegm can indicate an infection. Black phlegm can also indicate a fungal infection.

Learn more on colds versus allergies and reasons for coughing up phlegm without feeling ill.

Read this article in Spanish.

What Can Sputum (phlegm) Tell Us?

The body produces mucus, also known as phlegm or sputum, to protect sensitive tissues in the airways. Changes in the sputum color, thickness, or quantity of phlegm may indicate a health problem, such as a respiratory infection, lung disease, or cancer.

Mucus consists of mucins and other proteins. The body produces mucus to keep the thin, delicate tissues of sensitive areas — such as the respiratory tract — moist.

Mucus lines and protects sensitive surfaces inside the body, and it helps trap and remove small particles of foreign matter that may pose a threat.

Sometimes, the lungs produce too much mucus. The body attempts to expel this excess by coughing it up as sputum or phlegm.

Here, learn about what changes in phlegm can mean and what to do if they happen.

The different colors of sputum can indicate whether a person has a health problem and what kind of problem they may have. Here are some of the colors that may be present.

There are many reasons why the body produces excess sputum or sputum with an unusual color or texture.

They include:

Smoking

Smoking increases the risk of various diseases, including lung cancer, chronic bronchitis, and chronic obstructive pulmonary disease (COPD).

One reason for excess mucus production may be to protect the lungs from damage due to particles.

However, one older study from 2011 suggested that smoking may suppress a protein known as Bik in the lungs of smokers with chronic bronchitis. Usually, this protein kills unwanted mucus cells. However, it seems that smoking may prevent this by reducing the action of Bik, resulting in excess mucus production.

What to know about smoker's cough.

Asthma

People with asthma have airways that are sensitive to allergens, such as pollen and air pollution. They also have a higher risk of respiratory infection.

These factors can lead to airway inflammation and cause the airways to produce additional mucus as they try to protect themselves.

Treatment options include identifying and avoiding triggers and using inhalers to manage or prevent attacks.

Cystic fibrosis

A person with cystic fibrosis (CF) has inherited genetic features that cause the body to produce thick mucus. This unusually thick mucus can block the airways and cause breathing difficulties.

The thick mucus in CF becomes an ideal environment for bacteria to grow, increasing the risk of infection.

Doctors often diagnose CF at birth, as it is part of the screening process for newborns. A person with CF will likely receive ongoing follow-up care.

Treatment options include:

drugs that help change the protein that causes mucus to thicken

mechanical removal of sputum

breathing support

The person will also need to take measures to avoid respiratory infections, as they can be life threatening in people with CF.

Respiratory tract infections

Sputum that is a different color from saliva may be a sign of a lower respiratory tract infection (RTI), which affects the lungs. Examples include bacterial or viral pneumonia and bronchitis.

With bacterial RTIs, sputum may also have a thick consistency and an unpleasant odor.

In the early stages of an RTI, sputum may be dark green or yellow. As the infection retreats, the color becomes lighter. It is the presence of an enzyme called myeloperoxidase that gives the sputum its green color during an infection.

Here are some examples of RTIs that may affect sputum.

COVID-19

Some people with COVID-19 have a dry cough, but around 30% have a cough that produces sputum. This can aggravate breathing problems.

One study suggests that those with breathing problems early in the disease may develop more severe symptoms and have a worse outcome than those who first notice a fever, pain, and diarrhea.

Other symptoms of COVID-19 include:

Treatment options include:

isolating

resting at home

using over-the-counter (OTC) pain relief medications

A doctor may prescribe antiviral medications if a person has a high risk of severe infection due to another health condition.

A person needs emergency medical help if they have:

Flu

Flu, or influenza, is a viral infection. A person with the flu may have green or yellow phlegm.

Other symptoms include:

People may treat the flu by:

resting at home

avoiding other people

using OTC pain relievers

taking antiviral drugs, if a doctor prescribes them

Vaccines can help prevent the flu.

Bronchitis

Bronchitis is an infection of the lung's main airways: the bronchi. They become inflamed and produce extra mucus. A person may cough up clear, gray, or greenish phlegm.

Acute bronchitis lasts about 3 weeks and usually goes away without treatment. Treatment includes resting, drinking plenty of fluids, and taking nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.

Chronic bronchitis lasts at least 3 months and is recurring. It is a symptom of other lung conditions, including emphysema and COPD. Avoiding smoking can help manage it.

If symptoms worsen or do not improve, people should speak with a doctor. The following groups have a greater risk of developing pneumonia:

older adults

those who smoke

people with compromised immune systems or other health conditions

Pneumonia

A person with pneumonia may have a dry cough or a cough that produces thick sputum that is yellow, green, brown, or blood-stained.

This is a viral or bacterial infection that leads to the swelling of lung tissue.

Other common symptoms include:

If someone thinks they have pneumonia, they should seek medical advice. Anyone who is unable to breathe or is coughing up blood should seek emergency help.

Treatment options include resting, drinking plenty of fluids, and taking antibiotics if the infection is bacterial. Some people may need to spend time in the hospital.

Tuberculosis

Tuberculosis (TB) is a bacterial infection. It usually affects the lungs but can occur in other parts of the body, such as the stomach.

A person with TB in the lungs may cough up blood or blood-streaked phlegm.

Other symptoms include:

a severe cough lasting 3 weeks or longer

chest pain

weakness and fatigue

low appetite and weight loss

fever and chills

night sweats

People with TB will need a course of antibiotics lasting several months, but some types of TB are becoming resistant to antibiotics.

Heart Failure: Why Minorities Are At A Disadvantage

Welcome, everyone, to this roundtable discussion on heart failure. I'm Dr. John Whyte, the chief medical officer at WebMD. Six million Americans have heart failure. It's one of the most common reasons people are admitted to the hospital. And despite all the advances we have in testing and treatment, not everyone benefits from that.

What do I mean? Blacks are diagnosed at a much later stage and advanced disease compared to whites. When they do get treated, they often don't receive the same type of therapies, and they're often not treated by expert cardiologists compared to whites. It's a similar situation for Hispanics. But I'll tell you, we don't even have good data to truly know the extent.

And women? Guess what? Women of all races and ethnicities are also diagnosed later and at more advanced stages. What do we do about this? How do we address it?

To help unpack it all, I'm joined by two experts. Dr. Reginald Robinson is a cardiologist at MedStar Health, and he's the president of the Board of the Directors for the Eastern States region of the American Heart Association. And Dr. Abiodun Ishola, he's an interventional cardiologist at St. Elizabeth Health Care.

Doctors, thanks for joining me.

ABIODUN ISHOLA

Thanks for having us.

REGINALD ROBINSON

Thanks for having us.

JOHN WHYTE

So Dr. Robinson, I want to ask you, why are we diagnosing heart failure so late in life? Typically 65 and 70 for people of color-- men of color, even, and women of color. And then they're at advanced stage.

What's going on here? What's the etiology? Is it that they're not coming to the doctor? They don't recognize the symptoms? The doctors are dismissing it, saying, you know, I'm not even going to check? What's the situation here?

REGINALD ROBINSON

There are multiple areas, and you hear these terms now that are coming to the forefront with health equity and the social determinants of health. Social determinants of health, or how people live, pray, celebrate in their environment. And we don't really think about how environment impacts outcome. We've been taught in medical school that ACE inhibitors or anything that ends in '-april'-- like enalapril, ramipril-- or an ARB or angiotensin receptor blocker that ends in '-sartan'-- like losartan-- they didn't work as well in African-Americans.

But we know that we're not a heterogeneous population. So if it's the standard of care, we shouldn't withhold standard of care from any treatment regimen. So again, we have to look at not only patients that come into the hospital, but how do we follow up some of these patients that zip code will dictate their outcome?

JOHN WHYTE

And I want to push you on this a little. Do we change treatment strategies based on a person's race, gender, ethnicity? Is there variability of drug response, meaning that certain populations will respond better to certain types of medications? Should there be a difference in treatment strategy?

REGINALD ROBINSON

Well, again, that's been the traditional treatment. Older studies looked at hydralazine and isosorbide. A small subset of population showed that an African-American population did better when we actually used and implemented that on top of traditional treatment. But again, if its standard of care, we still should use standard of care.

JOHN WHYTE

Why aren't they being offered it? We know that from the data.

REGINALD ROBINSON

Yes. A lot of issues. One, we may not even think to go through the insurance company. They're doing it less so now, but there tends to be a struggle when you order for a patient that has Medicare or Medicaid. You have to go through prior authorization sometimes to get those patients on it, where you may not have to do that in a traditional insurance carrier.

So I'm seeing it less and less, but it still has been an issue, and I guess we have to really push that. We have to push getting those standard of care treatment for patients, because we know that's best for them.

JOHN WHYTE

Dr. Ishola is an interventional cardiologist, so I won't push him on this question, but I'm going to push it back to you, if I may. You're saying social determinants of health-- how they pray, how they eat-- should I be asking patients, when I'm trying to manage heart failure, about food insecurity? Should I be asking them about their stress? Should I be asking them if they're depressed?

ABIODUN ISHOLA

I'm a big fan-- or my philosophy is, you have to treat the whole person. You can't just treat the symptom. You can't just treat one facet of a person. To get good outcomes, you have to see the person as a whole and understand that it's critical to treat, also, the mindset and also the disease process itself. We know the lifestyle is a big factor when it comes to high blood pressure.

So you can give all the medications you want, for example. But when you have high salt intake, a very sedentary lifestyle, and mindset of not going to the doctor except when you're sick, all you're doing is really treating the disease and not the person. So I would definitely-- personally, I believe you can't isolate the patient and the mindset from the disease process to get a durable, lasting result, and that is what we've seen over time.

And we do understand that when patients feel like they can open up to their physician and the doctor actually cares about what is going on, they reveal to you things that they never talk about to other doctors, which is one of the major issues we've seen with disparity. When we have underrepresentation of minority doctors or female doctors, a lot of times people don't feel like the doctor necessarily understands them, and wouldn't open up about those social factors as limiting care or limiting a lifestyle issue. So it's a multifaceted issue, but definitely you have to focus on the whole person to get a durable outcome.

REGINALD ROBINSON

We've been talking about cardiovascular disease as the leading cause of death since the first pandemic, right? And why is that? Because we've been focusing on the peak of that pyramid-- how someone eats, their exercise level. But the base of the pyramid is actually something we really haven't covered-- how are those social determinants of health?

So if someone doesn't have access to transportation to get to their doctor's office, or they have to wait on metro access or some kind of delivery service to take them there. And when you look at studies showing hospitalization and readmission rates for African-Americans or Latino-Americans, the morbidity, or someone dying in the hospital, is probably smaller, but when you look at 30-day, 60-day, 100-day readmission rate, that tends to be a lot higher. You're going to see them back.

JOHN WHYTE

I want to turn to the Hispanic population. We often don't have good data about that. In terms of when we collect data, that's often a missing data point, about ethnicity. What exactly do we know about the prevalence of heart failure in Hispanic populations? Dr. Robinson?

REGINALD ROBINSON

It was interesting. In this study, they looked at a population of Hispanic patients, and it's harder to do that because they're not a heterogeneous group. You might see some from immigrants from El Salvador different than if we lump them in with someone from Spain or Cuba or Mexico-- the same thing we see in the African-American population, where, when they look at white population, the people that lived in the non-distressed populations versus the distressed, there was a huge variable. And you had to take in people living in urban environments versus rural environments access to care.

So we do know that there a non-heterogeneous group in the Hispanic population, and looking at those factors and including those is important to really trying to tease through the data.

JOHN WHYTE

And we need to collect more data in terms of different ethnicities in general, not just Hispanics. Doctor Ishola, what about the presentation of heart failure in women? Is it different than it is in men, similar as heart attacks are different-- sometimes more subtle? How do women typically present with heart failure?

ABIODUN ISHOLA

Yeah, kind of like in coronary disease, women tend to present a lot different. Part of the issue is the lack of awareness sometimes as well. You know, people present with shortness of breath, palpitations, fatigue, a decline in functional status, and sometimes those symptoms have been masked as something else-- maybe panic attacks and anxiety attacks-- and overlooked for a while. A lot of studies have shown, recently, women and Blacks and people of lower socioeconomic status tend to be diagnosed in emergency rooms than their white counterparts, male counterparts, which tells us those symptoms are being overlooked for multiple reasons.

We do know that in coronary disease, the estrogen protective effects delays the diagnosis of CAD or gives them protection until they're in their 60s. So we do understand that most women don't develop significant heart failure till their 50s and 60s because there's less prevalence of coronary disease.

JOHN WHYTE

10 years later, typically, than men, in general.

ABIODUN ISHOLA

Exactly. Exactly. The second issue is a lot of women, when they develop heart failure, tend to develop more diastolic heart failure than women, especially in their 60s and 70s, than systolic heart failure. And also, the knowledge base of treating that is variable from place to place. And I think that has played a factor as well. The last issue is the mortality factor as well.

Even though women don't die as much compared to men, they have significant morbidity and re-hospitalization. So I think there's a lot of those factors playing a role. One is atypical presentation, just like in coronary disease. And two is the late diagnosis for the facts that we've talked about.

JOHN WHYTE

Gentlemen, let's talk about solutions, right? So we know there's disparate care. How do we help eliminate disparities when we're addressing heart failure in people of color and women?

REGINALD ROBINSON

Well, we just celebrated Martin Luther King celebration, and one of his biggest things-- he said that health care is one of the biggest issues when you look at disparities, when you look at overall outcomes.

JOHN WHYTE

The greatest disparity is health.

REGINALD ROBINSON: And without a healthy workforce, without a healthy population, you can't move the needle forward. So like we're having this discussion with physicians on this chat, we need to have politicians on the chat, we need to have faith-based organizations on the chat, we need to have people that are actually on the ground doing things within the community. Because, again, physicians, we've been doing this for over 100 years, over a century mark. The Heart Association is almost 100 years old in 2024, and we've been discussing this.

But we need to bring legislators in to look at those social-- how social determinants impact health. Otherwise we'll continue to look at this.

JOHN WHYTE

Dr. Ishola, the final word.

ABIODUN ISHOLA

I would say the way forward is to realize we've kind of talked about as the socioeconomic factors play as much as a role in preventing recurrence as much as the disease process itself. And there is really no way to untie those two processes. They're very interlinked.

So to really make progress when it comes to heart disease, we have to focus on the social and economic factors playing a major role in the prevalence of what we see today.

JOHN WHYTE

Doctors, I want to thank you both for raising awareness, for helping us to think through what are the strategies and solutions to creating more equity in the treatment of heart failure.

ABIODUN ISHOLA

Thank you.

REGINALD ROBINSON

Thank you for having us.

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JOHN WHYTE

Welcome, everyone, to this roundtable discussion on heart failure. I'm Dr. John Whyte, the chief medical officer at WebMD. Six million Americans have heart failure. It's one of the most common reasons people are admitted to the hospital. And despite all the advances we have in testing and treatment, not everyone benefits from that.

What do I mean? Blacks are diagnosed at a much later stage and advanced disease compared to whites. When they do get treated, they often don't receive the same type of therapies, and they're often not treated by expert cardiologists compared to whites. It's a similar situation for Hispanics. But I'll tell you, we don't even have good data to truly know the extent.

And women? Guess what? Women of all races and ethnicities are also diagnosed later and at more advanced stages. What do we do about this? How do we address it?

To help unpack it all, I'm joined by two experts. Dr. Reginald Robinson is a cardiologist at MedStar Health, and he's the president of the Board of the Directors for the Eastern States region of the American Heart Association. And Dr. Abiodun Ishola, he's an interventional cardiologist at St. Elizabeth Health Care.

Doctors, thanks for joining me.

ABIODUN ISHOLA

Thanks for having us.

REGINALD ROBINSON

Thanks for having us.

JOHN WHYTE

So Dr. Robinson, I want to ask you, why are we diagnosing heart failure so late in life? Typically 65 and 70 for people of color-- men of color, even, and women of color. And then they're at advanced stage.

What's going on here? What's the etiology? Is it that they're not coming to the doctor? They don't recognize the symptoms? The doctors are dismissing it, saying, you know, I'm not even going to check? What's the situation here?

REGINALD ROBINSON

There are multiple areas, and you hear these terms now that are coming to the forefront with health equity and the social determinants of health. Social determinants of health, or how people live, pray, celebrate in their environment. And we don't really think about how environment impacts outcome. We've been taught in medical school that ACE inhibitors or anything that ends in "-april"-- like enalapril, ramipril-- or an ARB or angiotensin receptor blocker that ends in "-sartan"-- like losartan-- they didn't work as well in African-Americans.

But we know that we're not a heterogeneous population. So if it's the standard of care, we shouldn't withhold standard of care from any treatment regimen. So again, we have to look at not only patients that come into the hospital, but how do we follow up some of these patients that zip code will dictate their outcome?

JOHN WHYTE

And I want to push you on this a little. Do we change treatment strategies based on a person's race, gender, ethnicity? Is there variability of drug response, meaning that certain populations will respond better to certain types of medications? Should there be a difference in treatment strategy?

REGINALD ROBINSON

Well, again, that's been the traditional treatment. Older studies looked at hydralazine and isosorbide. A small subset of population showed that an African-American population did better when we actually used and implemented that on top of traditional treatment. But again, if its standard of care, we still should use standard of care.

JOHN WHYTE

Why aren't they being offered it? We know that from the data.

REGINALD ROBINSON

Yes. A lot of issues. One, we may not even think to go through the insurance company. They're doing it less so now, but there tends to be a struggle when you order for a patient that has Medicare or Medicaid. You have to go through prior authorization sometimes to get those patients on it, where you may not have to do that in a traditional insurance carrier.

So I'm seeing it less and less, but it still has been an issue, and I guess we have to really push that. We have to push getting those standard of care treatment for patients, because we know that's best for them.

JOHN WHYTE

Dr. Ishola is an interventional cardiologist, so I won't push him on this question, but I'm going to push it back to you, if I may. You're saying social determinants of health-- how they pray, how they eat-- should I be asking patients, when I'm trying to manage heart failure, about food insecurity? Should I be asking them about their stress? Should I be asking them if they're depressed?

ABIODUN ISHOLA

I'm a big fan-- or my philosophy is, you have to treat the whole person. You can't just treat the symptom. You can't just treat one facet of a person. To get good outcomes, you have to see the person as a whole and understand that it's critical to treat, also, the mindset and also the disease process itself. We know the lifestyle is a big factor when it comes to high blood pressure.

So you can give all the medications you want, for example. But when you have high salt intake, a very sedentary lifestyle, and mindset of not going to the doctor except when you're sick, all you're doing is really treating the disease and not the person. So I would definitely-- personally, I believe you can't isolate the patient and the mindset from the disease process to get a durable, lasting result, and that is what we've seen over time.

And we do understand that when patients feel like they can open up to their physician and the doctor actually cares about what is going on, they reveal to you things that they never talk about to other doctors, which is one of the major issues we've seen with disparity. When we have underrepresentation of minority doctors or female doctors, a lot of times people don't feel like the doctor necessarily understands them, and wouldn't open up about those social factors as limiting care or limiting a lifestyle issue. So it's a multifaceted issue, but definitely you have to focus on the whole person to get a durable outcome.

REGINALD ROBINSON

We've been talking about cardiovascular disease as the leading cause of death since the first pandemic, right? And why is that? Because we've been focusing on the peak of that pyramid-- how someone eats, their exercise level. But the base of the pyramid is actually something we really haven't covered-- how are those social determinants of health?

So if someone doesn't have access to transportation to get to their doctor's office, or they have to wait on metro access or some kind of delivery service to take them there. And when you look at studies showing hospitalization and readmission rates for African-Americans or Latino-Americans, the morbidity, or someone dying in the hospital, is probably smaller, but when you look at 30-day, 60-day, 100-day readmission rate, that tends to be a lot higher. You're going to see them back.

JOHN WHYTE

I want to turn to the Hispanic population. We often don't have good data about that. In terms of when we collect data, that's often a missing data point, about ethnicity. What exactly do we know about the prevalence of heart failure in Hispanic populations? Dr. Robinson?

REGINALD ROBINSON

It was interesting. In this study, they looked at a population of Hispanic patients, and it's harder to do that because they're not a heterogeneous group. You might see some from immigrants from El Salvador different than if we lump them in with someone from Spain or Cuba or Mexico-- the same thing we see in the African-American population, where, when they look at white population, the people that lived in the non-distressed populations versus the distressed, there was a huge variable. And you had to take in people living in urban environments versus rural environments access to care.

So we do know that there a non-heterogeneous group in the Hispanic population, and looking at those factors and including those is important to really trying to tease through the data.

JOHN WHYTE

And we need to collect more data in terms of different ethnicities in general, not just Hispanics. Doctor Ishola, what about the presentation of heart failure in women? Is it different than it is in men, similar as heart attacks are different-- sometimes more subtle? How do women typically present with heart failure?

ABIODUN ISHOLA

Yeah, kind of like in coronary disease, women tend to present a lot different. Part of the issue is the lack of awareness sometimes as well. You know, people present with shortness of breath, palpitations, fatigue, a decline in functional status, and sometimes those symptoms have been masked as something else-- maybe panic attacks and anxiety attacks-- and overlooked for a while. A lot of studies have shown, recently, women and Blacks and people of lower socioeconomic status tend to be diagnosed in emergency rooms than their white counterparts, male counterparts, which tells us those symptoms are being overlooked for multiple reasons.

We do know that in coronary disease, the estrogen protective effects delays the diagnosis of CAD or gives them protection until they're in their 60s. So we do understand that most women don't develop significant heart failure till their 50s and 60s because there's less prevalence of coronary disease.

JOHN WHYTE

10 years later, typically, than men, in general.

ABIODUN ISHOLA

Exactly. Exactly. The second issue is a lot of women, when they develop heart failure, tend to develop more diastolic heart failure than women, especially in their 60s and 70s, than systolic heart failure. And also, the knowledge base of treating that is variable from place to place. And I think that has played a factor as well. The last issue is the mortality factor as well.

Even though women don't die as much compared to men, they have significant morbidity and re-hospitalization. So I think there's a lot of those factors playing a role. One is atypical presentation, just like in coronary disease. And two is the late diagnosis for the facts that we've talked about.

JOHN WHYTE

Gentlemen, let's talk about solutions, right? So we know there's disparate care. How do we help eliminate disparities when we're addressing heart failure in people of color and women?

REGINALD ROBINSON

Well, we just celebrated Martin Luther King celebration, and one of his biggest things-- he said that health care is one of the biggest issues when you look at disparities, when you look at overall outcomes.

JOHN WHYTE

The greatest disparity is health.

REGINALD ROBINSON: And without a healthy workforce, without a healthy population, you can't move the needle forward. So like we're having this discussion with physicians on this chat, we need to have politicians on the chat, we need to have faith-based organizations on the chat, we need to have people that are actually on the ground doing things within the community. Because, again, physicians, we've been doing this for over 100 years, over a century mark. The Heart Association is almost 100 years old in 2024, and we've been discussing this.

But we need to bring legislators in to look at those social-- how social determinants impact health. Otherwise we'll continue to look at this.

JOHN WHYTE

Dr. Ishola, the final word.

ABIODUN ISHOLA

I would say the way forward is to realize we've kind of talked about as the socioeconomic factors play as much as a role in preventing recurrence as much as the disease process itself. And there is really no way to untie those two processes. They're very interlinked.

So to really make progress when it comes to heart disease, we have to focus on the social and economic factors playing a major role in the prevalence of what we see today.

JOHN WHYTE

Doctors, I want to thank you both for raising awareness, for helping us to think through what are the strategies and solutions to creating more equity in the treatment of heart failure.

ABIODUN ISHOLA

Thank you.

REGINALD ROBINSON

Thank you for having us.

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