Chronic liver disease (CLD) and cirrhosis are among the top causes of death among US adults and ranked in 2019 in the top 10 causes among adults ages 25-74 for all races and those of Hispanic origin. [1] From 2012 to 2016, hospitalizations due to CLD increased in the older adult population, while decreasing in younger age groups. [2] In terms of race and ethnicity, after Japanese Americans, Hispanic Americans have the highest prevalence of CLD in the US and have one of the highest rates due to non-alcoholic fatty liver disease and alcoholic liver disease. [3] Of 13 US states with the highest mortality due to liver disease, 7 have greater-than-average Hispanic populations, [4] and US-born Hispanic individuals have higher mortality from CLD than foreign-born Hispanics. [5]

Hispanic Americans also have a higher incidence of heart failure (HF) than non-Hispanic whites. [6] For example, using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research death certificate database (1999-2018), Khan et al. found that Hispanic individuals had a higher overall decline in total cardiovascular disease (CVD) and in ischemic heart disease than non-Hispanic whites; however, this group had a greater increase in mortality rates due to HF in those <45 and 45-64 years. [7] Upon admission for HF hospitalization, Hispanic Americans also had a lower left ventricular ejection fraction value than non-Hispanic whites or blacks. [8] Other studies found health disparity in HF readmission and short-term mortality in the Hispanic population when compared to Non-Hispanic whites, with higher mortality rates from overall CVD in foreign-born vs. US-born Hispanics. [9], [10]

HF and liver disease (LD) are closely related in their pathophysiological effects. [11] For example, HF causes LD complications by way of congestive hepatopathy. [12], [13] In congestive hepatopathy, elevated right-sided venous pressure leads to increased hepatic venous pressure, decreased hepatic blood flow, and decreased arterial oxygen saturation. [14] LD can cause cardiac symptoms via cirrhotic cardiomyopathy, with its ensuing systolic dysfunction, diastolic dysfunction, and electrophysiologic abnormalities. [12], [14] In the European/Israeli SURVIVE study, abnormalities in liver function tests were associated with increased risk of mortality in the short- and intermediate-term in patients hospitalized for acute decompensated HF. [15]

The Hispanic population in the US has clear health disparities in LD and HF mortality. [3], [4], [5], [7], [10], [16] Indeed, US-born Hispanics had a higher prevalence of heart disease, obesity, hypertension, smoking, and cancer than foreign-born Hispanics. [17] Another report found that the mortality rate from CLD was two times higher among US-born vs. foreign-born Hispanics. [3] A study of the National Center for Health Statistics mortality file showed that foreign-born Hispanics (Mexican, Cuban, and Puerto Rican) had higher age-adjusted death rates for all-cause mortality, CVD, ischemic heart disease, and cerebrovascular disease than US-born Hispanics, [10] a phenomenon that reflects the “immigrant health paradox” known as the “Hispanic Paradox” first described by Markides et al. in 1986. [18]

Despite the reported association of LD and HF with higher mortality rates in the Hispanic population, few studies have examined the effect of co-occurring LD and HF on health outcomes among US older adults, a population expected to reach 94.7 million by 2060, of which ~19.9 million will be Hispanic. [19] The objective of this study is to examine the nativity differences in mortality associated with LD, HF, or both, among Mexican Americans aged 75 years and older over 13 years of follow up. We hypothesize that those with co-occurring LD and HF will be at higher risk of mortality compared to those with HF only, LD only, or neither; and that there will be differences by nativity status.