The current state of ethnic and racial disparities in cardiovascular care: lessons from the past and opportunities for the future. Curr Cardiol Rep. 2014;16:530. [PMID: 25135343 DOI: 10.1007/s11886-014-0530-3]

General practitioners' views on cardiovascular prevention for ethnic minorities-a qualitative study in the Netherlands

OBJECTIVES

While ethnic minorities in Europe are disproportionally affected by cardiovascular disease (CVD), little is known about how general practitioners (GPs) perceive differences in risk or care needs across ethnic minority groups. Therefore, we explored GPs' views on whether ethnicity influences cardiovascular risk, whether a culturally sensitive approach is warranted, on potential barriers in the provision of such care, and to find potential opportunities to improve cardiovascular prevention for these groups.

METHODS

We conducted a qualitative study by interviewing GPs practising in The Netherlands. The interviews were semistructured, audio-recorded, and analysed by 2 researchers using thematic analysis.

RESULTS

We interviewed 24 Dutch GPs (50% male). GPs' views on the impact of ethnicity on CVD risk varied widely, yet it was generally recognized as a relevant factor in cardiovascular prevention for most minority groups, prompting earlier case-finding of high-risk patients. While GPs were aware of sociocultural differences, they emphasized an individualized approach. Perceived limitations were language barriers and unfamiliarity with sociocultural customs, leading to a need for continuing medical education on culturally sensitive care and reimbursement of telephone interpreting services.

CONCLUSION

Dutch GPs have differing views on the role of ethnicity in evaluating and treating cardiovascular risk. Despite these differences, they emphasized the importance of a personalized and culturally sensitive approach during patient consultations and expressed a need for continuing medical education. Additional research on how ethnicity influences CVD risk may strengthen cardiovascular prevention in increasingly diverse primary care populations.

Clinical value of a tool for managing oral anticoagulation in nonvalvular atrial fibrillation in primary health care. Randomized clinical trial

INTRODUCTION AND OBJECTIVES

The management of atrial fibrillation is complex and requires improvement at strategic points, such as in the control of patients treated with vitamin K antagonists. The aim of this study was to evaluate the impact on health outcomes of a nonvalvular atrial fibrillation decision support tool based on visualization of the time in therapeutic range in primary care.

METHODS

The present randomized clinical trial was conducted in 2018 with a 1-year follow-up in 325 primary care centers in Catalonia. In the intervention centers, the decision support tool was installed to control the time in therapeutic range of patients treated with vitamin K antagonists. The tool was not visualized in the control group.

RESULTS

In total, 44 556 patients were studied. The intervention protected against admission for stroke (adjusted odds ratio [OR], 0.70; 95% confidence interval [95%CI], 0.55-0.88). The number needed to treat was 3502 (95%CI, 3305-3725) while the number of admissions for stroke avoided was 12.63 (95%CI, 11.88-13.38). The intervention also protected against mortality (adjusted OR, 0.78; 95%CI, 0.67-0.90), with a number needed to treat of 13 687 (95%CI, 10 789-18 714) and number of deaths avoided of 3.23 (95%CI, 2.36-4.10).

CONCLUSIONS

The decision support tool was associated with slight reductions in the numbers of admissions for ischemic stroke and mortality. Although the follow-up time was short and the effect of the intervention was small, the results are valuable and could improve implementation of the tool. This clinical trial was registered with ClinicalTrials.gov (NCT03367325).

Use of Calcium Modification During Percutaneous Coronary Intervention After Introduction of Coronary Intravascular Lithotripsy

Background

Calcified coronary lesions are a challenge for percutaneous coronary interventions (PCIs). Coronary intravascular lithotripsy (IVL) is a novel calcium modification technology approved for commercial use in February 2021, but little is known about its uptake in US clinical practice.

Methods

We described trends in use of calcium modification strategies, variation in use across hospitals, and predictors of calcium modification and IVL use in PCI. We included National Cardiovascular Data Registry CathPCI Registry patients who underwent PCI between April 1, 2018, and December 31, 2022. We examined trends and hospital variation in calcium modification and IVL use. We used multivariate hierarchical logistic regression to identify predictors of calcium modification and IVL use at hospitals in 2022.

Results

Of 2,733,494 PCIs across 1676 hospitals over 4.75 years, 11.4% were performed with calcium modification. Coronary IVL use increased rapidly from 0% of PCIs in Q4 2020 to 7.8% of PCIs in Q4 2022, which was accompanied by an overall increase in use of all calcium modification strategies (11.1%-16.0%) during this period with a slight corresponding decrease in coronary atherectomy use (5.4%-4.4%). In 2022, there was wide variation in IVL use across hospitals (median, 3.86%; IQR, 0%-8.19%), with IVL being the most common calcium modification strategy in 48% of hospitals. The treating hospital was the strongest predictor of calcium modification (median odds ratio [OR], 2.49; 95% CI, 2.40-2.57) and IVL use (median OR, 2.89; 95% CI, 2.74-3.04).

Conclusions

IVL has rapidly changed the landscape of calcium modification use for PCI, although there remains wide variation across hospitals.

The Long-Term Effect of Financial Penalties on 30-Day Hospital Readmission Rates

BACKGROUND

Although the immediate effect of financial penalties imposed by the Hospital Readmissions Reduction Program (HRRP) was a decrease in 30-day hospital readmission rates, the long-term effects are unclear. The authors studied 30-day readmissions before and immediately after HRRP penalties and during the most recent period before the COVID-19 pandemic and examined whether readmission trends differed between penalized and non-penalized hospitals.

METHODS

Centers for Medicare & Medicaid Services hospital archive data and US Census Bureau data were used to analyze hospital characteristics, including readmission penalty status, and hospital service area (HSA) demographic information, respectively. These two datasets were matched by HSA crosswalk files, available through the Dartmouth Atlas files. Using data from 2005-2008 as baseline, the authors examined hospital readmission trends before (2008-2011) and after penalties (during three periods: 2011-2014, 2014-2017, 2017-2019). Mixed linear models were used to examine readmission trends through periods, and differences by hospital penalty status without and with adjustment for hospital characteristics and HSA demographic information.

RESULTS

For all hospitals combined, rates for 2008-2011 vs. 2011-2014 were as follows: pneumonia, 18.6% vs. 17.0%; heart failure (HF), 24.8% vs. 22.0%; acute myocardial infarction (AMI), 19.7% vs. 17.0% (p < 0.001 for all three conditions). Rates for 2014-2017 vs. 2017-2019 were as follows: pneumonia, 16.8% vs. 16.8% (p = 0.87), HF, 21.7% vs. 21.9% (p < 0.001); AMI, 16.0% vs. 15.8% (p < 0.001). Compared to penalized hospitals, using difference-in-differences, non-penalized hospitals had a significantly greater increase for two conditions between the 2014-2017 and 2017-2019 periods: pneumonia 0.34%, p < 0.001; and HF 0.24%, p = 0.002.

CONCLUSION

Long-term readmission rates are lower than pre-HRRP rates, with recent trends decreasing further for AMI, stabilizing for pneumonia, and increasing for HF.

Contribution of life course cardiovascular risk factors to racial disparities in dementia incidence

Background

Racial disparities in dementia outcomes persist in the United States. Targeting modifiable risk factors, including cardiovascular risk factors (CVRFs), is a conceivable way to reduce health disparities. Life course CVRFs are often higher in non-White adults and are associated with risk of dementia, but it is unknown whether they contribute to racial disparities in dementia and cognition.

Methods

Using a pooled cohort of 4,159 White and 939 Black participants aged 65-95 years, we conducted a mediation analysis to estimate the proportional effect of race on dementia that is explained by four CVRFs imputed over the life course (20-49, 50-69, and 70-89 years of age): body mass index, fasting glucose, systolic blood pressure, and low-density lipoprotein cholesterol.

Results

Compared to White participants, Black participants had greater risk of dementia (adjusted OR = 1.37; 95% CI: 1.17-1.60). BMI and fasting glucose over the life course were significant mediators of the effect of race on dementia risk, mediating 39.1% (95% CI: 10.5-67.8%) and 8.2% (95% CI: 0.1-16.2%) of the effect, adjusted for sex and age. All four CVRFs together were also significant mediators of the effect of race on scores on global cognition and processing speed, accounting for approximately 11% of the effect.

Conclusions

We found that CVRFs across the life course partially explain disparities in dementia risk and cognition in late-life. Improved prevention and treatment of CVRFs across the life course may be important to reduce health disparities for dementia.

Association between vehicle ownership and disparities in mortality after myocardial infarction

Background

Access to reliable transportation is fundamental in the management of chronic disease. The purpose of this study was to investigate the association between vehicle ownership at the neighborhood-level and long-term mortality after myocardial infarction (MI).

Methods

This is a retrospective observational study evaluating adult patients admitted for MI between January 1st, 2006, and December 31st, 2016. Neighborhoods were defined by census tract and household vehicle ownership data was obtained from the American Community Survey courtesy of the University of California, Los Angeles Center for Neighborhood Knowledge. Patients were divided into 2 groups: those living in neighborhoods with higher vehicle ownership, and those living in neighborhoods with lower vehicle ownership. The cutoff of 4.34% of households reporting not owning a vehicle was used to define a neighborhood as one with "higher" vs "lower" vehicle ownership as this was the median value for the cohort. The association between vehicle ownership and all-cause mortality after MI was assessed using Cox proportional hazards regression models.

Results

A total of 30,126 patients were included (age 68.1 +/- 13.5 years, 63.2% male). After adjusting for age, sex, race/ethnicity, and medical comorbidities, lower vehicle ownership was associated with increased all-cause mortality after MI (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.06-1.14; p<0.001). This finding remained significant after adjusting for median household income (HR 1.06; 95% CI 1.02-1.10; p = 0.007). Upon comparison of White and Black patients living in neighborhoods with lower vehicle ownership; Black patients were found to have an increased all-cause mortality after MI (HR 1.21, 95% CI 1.13-1.30, p<0.001), a difference which remained significant after adjusting for income (HR 1.20; 95% CI 1.12-1.29; p<0.001). There was no significant difference in mortality between White and Black patients living in neighborhoods with higher vehicle ownership.

Conclusion

Lower vehicle ownership was associated with increased mortality after MI. Black patients living in neighborhoods with lower vehicle ownership had a higher mortality after MI than White patients living in similar neighborhoods but Black patients living in neighborhoods with higher vehicle ownership had no worse mortality than their White counterparts. This study highlights the importance of transportation in determining health status after MI.

Differences in Determinants: Racialized Obstetric Care and Increases in U.S. State Labor Induction Rates

Induction of labor (IOL) rates in the United States have nearly tripled since 1990. We examine official U.S. birth records to document increases in states' IOL rates among pregnancies to Black, Latina, and White women. We test if the increases are associated with changes in demographic characteristics and risk factors among states' racial-ethnic childbearing populations. Among pregnancies to White women, increases in state IOL rates are strongly associated with changes in risk factors among White childbearing populations. However, the rising IOL rates among pregnancies to Black and Latina women are not due to changing factors in their own populations but are instead driven by changing factors among states' White childbearing populations. The results suggest systemic racism may be shaping U.S. obstetric care whereby care is not "centered at the margins" but is instead responsive to characteristics in states' White populations.

Clinical Outcomes of Telehealth in Patients With Coronary Artery Disease and Heart Failure During the COVID-19 Pandemic

The COVID-19 pandemic necessitated a rapid adoption of telehealth (TH); however, its safety in subspecialty clinical practice remains uncertain. To assess the clinical outcomes associated with TH use in patients with coronary artery disease and/or heart failure during the initial phase of the COVID-19 pandemic, eligible adult patients who saw cardiologists from March 1, 2020, to August 31, 2020 (TH period) were identified. Patients were divided into two 3-month subcohorts (TH1, TH2) and compared with corresponding 2019 prepandemic subcohorts. The primary outcome was cardiovascular (CV) events within 3 months after index visits. Secondary analysis was CV events in patients aged ≥75 years within 3-month follow-up associated with TH use. Multivariable logistic regression was used to evaluate the association between TH use and CV outcomes. The study cohort included 6,485 TH and 7,557 prepandemic patients. The mean age was 70 years, with 40% of patients aged ≥75 years and 35% women. TH visits accounted for 0% of visits during the prepandemic period, compared with 68% during the TH period. Telephone visits comprised ≥92% of all TH encounters. Compared with the prepandemic period, patients seen during the TH period had fewer overall CV events (adjusted odds ratio 0.78, 95% confidence interval 0.67 to 0.90). Patients aged ≥75 years had similar findings (adjusted odds ratio 0.70, 95% confidence interval 0.55 to 0.89). Additional analysis of CV outcome events within 6 months after index visits showed similar findings. In conclusion, TH largely by way of telephone encounters can be safely incorporated into the ambulatory cardiology practice regardless of age.

CKD-Associated Cardiovascular Mortality in the United States: Temporal Trends From 1999 to 2020

Rationale & Objective

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular (CV) mortality, but there are limited data on temporal trends disaggregated by sex, race, and urban/rural status in this population.

Study Design

Retrospective observational study.

Setting & Participants

The Centers for Disease Control and Prevention Wide-Ranging, Online Data for Epidemiologic Research database.

Exposure & Predictors

Patients with CKD and end-stage kidney disease (ESKD) stratified according to key demographic groups.

Outcomes

Etiologies of CKD- and ESKD-associated mortality between 1999 and 2000.

Analytical Approach

Presentation of age-adjusted mortality rates (per 100,000 people) characterized by CV categories, ethnicity, sex (male or female), age categories, state, and urban/rural status.

Results

Between 1999 and 2020, we identified 1,938,505 death certificates with CKD (and ESKD) as an associated cause of mortality. Of all CKD-associated mortality, the most common etiology was CV, with 31.2% of cases. Between 1999 and 2020, CKD-related age-adjusted mortality increased by 50.2%, which was attributed to an 86.6% increase in non-CV mortality but a 7.1% decrease in CV mortality. Black patients had a higher rate of CV mortality throughout the study period, although Black patients experienced a 38.6% reduction in mortality whereas White patients saw a 2.7% increase. Hispanic patients experienced a greater reduction in CV mortality over the study period (40% reduction) compared to non-Hispanic patients (3.6% reduction). CV mortality was higher in urban areas in 1999 but in rural areas in 2020.

Limitations

Reliance on accurate characterization of causes of mortality in a large dataset.

Conclusions

Among patients with CKD-related mortality in the United States between 1999 and 2020, there was an increase in all-cause mortality though a small decrease in CV-related mortality. Overall, temporal decreases in CV mortality were more prominent in Hispanic versus non-Hispanic patients and Black patients versus White patients.

Caregiver reports of physician risk counseling for adolescents with special health care needs

BACKGROUND

Research has indicated disagreement between physicians, caregivers, and adolescents with special health care needs regarding appropriate risk counseling.

OBJECTIVE

The study examines caregivers' perceptions of adolescent risk counseling. We hypothesize caregivers of adolescents with special healthcare needs will perceive a lower rate of risk counseling.

METHODS

Data come from the 2016 National Survey of Children's Health. The sample included 13,542 adolescents. Analysis completed using logistic regression with odds ratios.

RESULTS

The results indicate no difference in caregiver perceptions of risk counseling for adolescents with special healthcare needs. Gender, race/ethnicity, and relationship between caregiver and provider influenced perception of receipt of risk counseling, regardless of health status.

CONCLUSIONS

Although adolescents with special healthcare needs perceive their risk behavior counseling to be lacking in quantity/quality, caregivers perceive such counseling does occur. These results highlight the need for comprehensive risk counseling for groups at risk of known health disparities.

PRACTICE IMPLICATIONS

Physicians and providers should be provided with the training and resources needed to be comfortable to engage in risk counseling. Adolescents need the opportunity to see their provider privately, and education to advocate for information risky behaviors. Parents, providers, and adolescents should be included in future risk counseling intervention plans.

Variability in 30-day major amputation rates following endovascular peripheral vascular intervention for critical limb ischemia

Introduction: Patients with critical limb ischemia (CLI) can undergo endovascular peripheral vascular intervention (PVI) to restore blood flow and decrease risk of amputation. As a potential indicator of quality for CLI care, we sought to describe 30-day major amputation rates following PVI. We also examined rate variability, and patient-level and site-level factors predicting amputations, using a national electronic health record (EHR) database. Methods: Using the Cerner Health Facts de-identified EHR database, patients with CLI diagnosis codes undergoing PVI were identified. The rate of amputation within 30 days of PVI was calculated. Risk ratios predicting amputation were derived using a mixed effects Poisson regression model adjusting for 16 patient and clinical factors. Median risk ratios (MRRs) were calculated to quantify site-level variability in amputations. Results: A total of 20,204 PVI procedures for CLI from 179 healthcare sites were identified. Mean age at procedure was 69.0 ± 12.6 years, 58.0% were male, and 29.6% were persons of color. Amputation within 30 days of PVI occurred after 570 (2.8%) procedures. Malnutrition, previous amputation, diabetes, and being of Black race were predictors of amputation. Amputation rates across sites ranged from 0.0% to 10.0%. The unadjusted MRR was 1.40 (95% CI 1.35-1.46), which was attenuated after adjusting for patient-level factors (MRR 1.30, 95% CI 1.26-1.34) and site characteristics (MRR 1.11, 95% CI 1.09-1.13). Conclusions: Among PVI procedures for CLI treatment, 30-day amputation rates varied across institutions. Although patient-level factors explained some variability, site-level factors explained most variation in the rates of these outcomes.

Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease: A Cluster Randomized Clinical Trial

IMPORTANCE

Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes.

OBJECTIVE

To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs).

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention.

INTERVENTIONS

A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations.

MAIN OUTCOMES AND MEASURES

One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control).

RESULTS

Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001).

CONCLUSIONS AND RELEVANCE

The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03001713.

Temporal trends and in-hospital complications of catheter ablation for atrial fibrillation among patients with moderate and advanced chronic kidney diseases: 2005-2018

INTRODUCTION

Real-world data on atrial fibrillation (AF) ablation among moderate and advanced chronic kidney disease (CKD) patients have so far remained scarce, especially in-hospital AF ablation outcomes.

METHODS

We drew data from the US National Inpatient Sample to identify hospitalized patients who underwent AF ablation between 2005 and 2018, and further stratified by CKD classification. We assessed the trend of AF ablation, as well as its complications.

RESULTS

A total of 152 630 patients who were primarily hospitalized for AF and underwent ablation were estimated. Among these, CKD patients were found in a total of 1509 participants, with 978, 206, and 325 under CKD3, CKD4, and CKD5/ESKD, respectively. There was a significant increment in admission rates for AF ablation in the CKD population across all CKD classifications (p < .001). All CKD patients were statistically older, with higher coexisting comorbidities, while hypertension was found substantially lower than non-CKD patients (p ≤ .001). Importantly, CKD, especially CKD3 and CKD5/ESKD, was significantly associated with an increased risk of total complications, and total bleeding, Neurological complications were found statistically lower in CKD patients (p = .029), and no mortality rates were significantly different (p = .287).

CONCLUSION

Our study observed an increase in admission trends for AF ablation among moderate and advanced CKD patients from 2005 to 2018. CKD was strongly associated with higher procedure-related complications and bleeding, but neurological safety profiles and mortalities rates were nonsignificantly different.

The association of race with CPR quality following out-of-hospital cardiac arrest

INTRODUCTION

Previous studies have shown racial disparities in outcomes after out-of-hospital cardiac arrest. Although several treatment factors may account for these differences, there is limited information regarding differences in CPR quality and its effect on survival in underrepresented racial populations.

METHODS

We conducted a secondary analysis of data from patients enrolled in the Pragmatic Airway Resuscitation Trial (PART). We calculated compliance rates with AHA 2015 high quality CPR metrics as well as compliance to intended CPR strategy (30:2 or continuous chest compression) based on the protocol in place for the first responding EMS agency. The primary analysis used general estimating equations logistic regression to examine differences between black and white patients based on EMS-assessed race after adjustment for potential confounders. Sensitivity analyses examined differences using alternate race definitions.

RESULTS

There were 3004 patients enrolled in PART of which 1734 had > 2 minutes of recorded CPR data and an EMS-assessed race (1003 white, 555 black, 176 other). Black patients had higher adjusted odds of compression rate compliance (OR: 1.36, 95% CI: 1.02-1.81) and lower adjusted odds of intended CPR strategy compliance (OR: 0.78, 95% CI: 0.63-0.98) compared to white patients. Of 974 transported to the hospital, there was no difference in compliance metric estimates based on ED-reported race.

CONCLUSION

Compression rate compliance was higher in black patients however compliance with intended strategy was lower based on EMS-assessed race. The remaining metrics showed no difference suggesting that CPR quality differences are not important contributors to the observed outcome disparities by race.

Associations of Race and Ethnicity With Presentation and Outcomes of Hypertrophic Cardiomyopathy: JACC Focus Seminar 6/9

Significant racial and ethnicity-based disparities in clinical presentation, management, and outcome of hypertrophic cardiomyopathy (HCM) are reported. Black patients with HCM are more likely to present with heart failure but are less commonly referred for symptom management, sudden cardiac death stratification, surgical septal myectomy, or for implantable cardioverter-defibrillators, all interventions that increase survival. Prevalence of bystander cardiopulmonary resuscitation is lower for Black patients than for White patients. Black patients with HCM have decreased survival after hospital discharge following out-of-hospital cardiac arrest. Biomedical and social interventions are urgently needed to reduce ethnicity-based disparities, which have an impact on outcomes in HCM and other cardiovascular diseases. There is also a need to focus on implementation science to support durable adoption of evidence-based therapies in Black patients and communities.

Efficacy of Mobile Health for Self-management of Cardiometabolic Risk Factors: A Theory-Guided Systematic Review

BACKGROUND

Although mobile health (mHealth) technologies are burgeoning in the research arena, there is a lack of mHealth interventions focused on improving self-management of individuals with cardiometabolic risk factors (CMRFs).

OBJECTIVE

The purpose of this article was to critically and systematically review the efficacy of mHealth interventions for self-management of CMRF while evaluating quality, limitations, and issues with disparities using the technology acceptance model as a guiding framework.

METHODS

PubMed, CINAHL, EMBASE, and Lilacs were searched to identify research articles published between January 2008 and November 2018. Articles were included if they were published in English, included adults, were conducted in the United States, and used mHealth to promote self-care or self-management of CMRFs. A total of 28 articles were included in this review.

RESULTS

Studies incorporating mHealth have been linked to positive outcomes in self-management of diabetes, physical activity, diet, and weight loss. Most mHealth interventions included modalities such as text messaging, mobile applications, and wearable technologies. There was a lack of studies that are (1) in resource-poor settings, (2) theoretically driven, (3) community-engaged research, (4) measuring digital/health literacy, (5) measuring and evaluating engagement, (6) measuring outcomes related to disease self-management, and (7) focused on vulnerable populations, especially immigrants.

CONCLUSION

There is still a lack of mHealth interventions created specifically for immigrant populations, especially within the Latino community-the largest growing minority group in the United States. In an effort to meet this challenge, more culturally tailored mHealth interventions are needed.

Procedural Patterns and Safety of Atrial Fibrillation Ablation: Findings From Get With The Guidelines-Atrial Fibrillation

BACKGROUND

Catheter ablation is an increasingly used treatment for symptomatic atrial fibrillation (AF). However, there are limited prospective, nationwide data on patient selection and procedural characteristics. This study describes patient characteristics, techniques, treatment patterns, and safety outcomes of patients undergoing AF ablation.

METHODS

A total of 3139 patients undergoing AF ablation between 2016 and 2018 in the Get With The Guidelines-Atrial Fibrillation registry from 24 US centers were included. Patient demographics, medical history, procedural details, and complications were abstracted. Differences between paroxysmal and patients with persistent AF were compared using Pearson χ2 and Wilcoxon rank-sum tests.

RESULTS

Patients undergoing AF ablation were predominantly male (63.9%) and White (93.2%) with a median age of 65. Hypertension was the most common comorbidity (67.6%), and patients with persistent AF had more comorbidities than patients with paroxysmal AF. Drug refractory, paroxysmal AF was the most common ablation indication (class I, 53.6%) followed by drug refractory, persistent AF (class I, 41.8%). Radiofrequency ablation with contact force sensing was the most common ablation modality (70.5%); 23.7% of patients underwent cryoballoon ablation. Pulmonary vein isolation was performed in 94.6% of de novo ablations; the most common adjunctive lesions included left atrial roof or posterior/inferior lines, and cavotricuspid isthmus ablation. Complications were uncommon (5.1%) and were life-threatening in 0.7% of cases.

CONCLUSIONS

More than 98% of AF ablations among participating sites are performed for class I or class IIA indications. Contact force-guided radiofrequency ablation is the dominant technique and pulmonary vein isolation the principal lesion set. In-hospital complications are uncommon and rarely life-threatening.

Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality

BACKGROUND AND PURPOSE

The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata.

METHODS

Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme.

RESULTS

There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51-0.59], P<0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57-0.73], P<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94-1.0], P=0.086; large towns, 1.05 [1.01-1.09], P=0.009; small towns, 1.10 [1.06-1.15], P<0.001; micropolitan rural, 1.16 [1.11-1.21], P<0.001; and remote rural 1.21 [1.15-1.27], P<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00-1.26], P<0.001) to 2017 (adjusted odds ratio, 1.27 [1.13-1.42], P<0.001).

CONCLUSIONS

Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.

Guideline-directed therapies for comorbidities and clinical outcomes among individuals with atrial fibrillation

BACKGROUND

Comorbidities are common in patients with atrial fibrillation (AF) and affect prognosis, yet are often undertreated. However, contemporary rates of use of guideline-directed therapies (GDT) for non-AF comorbidities and their association with outcomes are not well described.

METHODS

We used the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF) to test the association between GDT for non-AF comorbidities and major adverse cardiac or neurovascular events (MACNE; cardiovascular death, myocardial infarction, stroke/thromboembolism, or new-onset heart failure), all-cause mortality, new-onset heart failure, and AF progression. Adjustment was performed using Cox proportional hazards models and logistic regression.

RESULTS

Only 6,782 (33%) of the 20,434 patients eligible for 1 or more GDT for non-AF comorbidities received all indicated therapies. Use of all comorbidity-specific GDT was highest for patients with hyperlipidemia (75.6%) and lowest for those with diabetes mellitus (43.1%). Use of "all eligible" GDT was associated with a nonsignificant trend toward lower rates of MACNE (HR 0.90 [0.79-1.02]) and all-cause mortality (HR 0.90 [0.80-1.01]). Use of GDT for heart failure was associated with a lower risk of all-cause mortality (HR 0.77 [0.67-0.89]), and treatment of obstructive sleep apnea was associated with a lower risk of AF progression (OR 0.75 [0.62-0.90]).

CONCLUSIONS

In AF patients, there is underuse of GDT for non-AF comorbidities. The association between GDT use and outcomes was strongest in heart failure and obstructive sleep apnea patients where use of GDT was associated with lower mortality and less AF progression.

Exploring the Health Care Challenges and Health Care Needs of Arabic-Speaking Immigrants with Cardiovascular Disease in Australia

The Arabic-speaking immigrant group, which makes up the fourth largest language group in Australia, has a high prevalence of cardiovascular disease. The objective of this study was to explore the health care challenges and needs of Arabic-speaking immigrants with cardiovascular disease (CVD), using a comparative approach with English-speaking patients with CVD as the comparable group. Methods: Participants were recruited from community settings in Melbourne, Australia. Face-to-face semi-structured individual interviews were conducted at the recruitment sites. All interviews were audio-taped, transcribed, and coded thematically. Results: 29 participants with CVD were recruited; 15 Arabic-speaking and 14 English-speaking. Arabic-speaking immigrants, and to a lesser extent English-speaking patients with CVD may have specific health care challenges and needs. Arabic-speaking immigrants’ health care needs include: effective health care provider (HCP)-patient communication, accessible care, participation in decision-making, and empowerment. English-speaking participants viewed these needs as important for CVD management. However, only a few English-speaking participants cited these needs as unmet health care needs. Conclusion: This study suggests that Arabic-speaking immigrants with CVD may have unique needs including the need for privacy, effective HCP-patient communication that takes into account patients’ limited English proficiency, and pharmacist-physician collaboration. Therefore, there may be a need to identify a health care model that can address these patients’ health care challenges and needs. This, in turn, may improve their disease management and health outcomes.

Importance of Early Diagnosis in Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) can lead to long-term systolic dysfunction, especially among black women. Hypertensive disorders of pregnancy (HDP) are the strongest risk factor for PPCM, but controversy remains on whether HDP predict a favorable outcome. Women with HDP are also often diagnosed with PPCM earlier than those without HDP. Our objective is to determine recovery of systolic function in patients with PPCM stratified by HDP, timing of diagnosis, and race. We conducted a retrospective cohort study of 220 patients (55% black) diagnosed with PPCM. Patients with PPCM and HDP were diagnosed earlier postpartum than patients without HDP (P=0.013), an effect that was most pronounced in nonblack patients. Rates of left ventricular ejection fraction (LVEF) recovery were similar among PPCM patients with and without HDP (68.4% versus 62.6%, P=0.425). In contrast, patients with PPCM diagnosed after 1-month postpartum had lower rates of LVEF recovery than patients diagnosed <1-month postpartum (53.7% versus 69.9%, P=0.035). LVEF at time of diagnosis is a strong predictor of LVEF recovery, and patients with PPCM diagnosed after 1-month postpartum had lower baseline LVEF compared to patients presenting earlier (P=0.041). The presence of HDP does not correlate with LVEF recovery in our racially diverse PPCM cohort. In contrast, early diagnosis portends a favorable outcome. Early diagnosis is associated with higher LVEF at presentation, likely explaining the improved outcomes in these women. These findings underscore the need for early monitoring and diagnosis, especially in at-risk and underserved populations.

Use of Percutaneous Coronary Intervention Among Black and White Patients With End-Stage Renal Disease in the United States

Background Racial disparities in invasive cardiac procedures such as percutaneous coronary intervention (PCI) in the general population are well documented; however, national-level data on such disparities in the end-stage renal disease (ESRD) population are lacking. We assessed racial differences in PCI between black and white patients with ESRD on maintenance dialysis. Methods and Results Using the US Renal Data System database, we abstracted Medicare inpatient procedure claims for PCI in a cohort of 268 575 Medicare-primary patients who initiated treatment on maintenance dialysis from January 1, 2009, through June 1, 2013. We conducted Cox regression analyses with PCI being the event, adjusted for demographic characteristics, Hispanic ethnicity, cause of ESRD, comorbidities, and socioeconomic factors. We also assessed the probability of PCI, accounting for death or transplant in competing risk regression models. The crude incidence rate of PCI among white patients was 25.8 per 1000 patient-years versus 15.5 per 1000 patient-years among black patients. Cox regression analyses demonstrated that black patients were significantly less likely to undergo PCI compared with white patients (adjusted hazard ratio: 0.64; 95% CI, 0.62-0.67; P<0.001). In the competing risk models, the racial gap for PCI among black and white patients remained significant with death (subdistribution hazard ratio: 0.81; 95% CI, 0.76-0.85; P<0.001) or transplant as a competing event (subdistribution hazard ratio: 0.67; 95% CI, 0.64-0.70; P<0.001). Conclusions A racial gap exists in PCI use among dialysis patients despite having comprehensive coverage with Medicare. These findings persisted despite accounting for demographic, clinical, socioeconomic factors, and death or transplant as competing events.

Heart Age, Cardiovascular Disease Risk, and Disparities by Sex and Race/Ethnicity Among New York City Adults

OBJECTIVES

Cardiovascular disease (CVD) is the leading cause of mortality in the United States. The risk for developing CVD is usually calculated and communicated to patients as a percentage. The calculation of heart age-defined as the predicted age of a person's vascular system based on the person's CVD risk factor profile-is an alternative method for expressing CVD risk. We estimated heart age among adults aged 30-74 in New York City and examined disparities in excess heart age by race/ethnicity and sex.

METHODS

We applied data from the 2011, 2013, and 2015 New York State Behavioral Risk Factor Surveillance System to the non-laboratory-based Framingham risk score functions to calculate 10-year CVD risk and heart age by sex, race/ethnicity, and selected sociodemographic groups and risk factors.

RESULTS

Of 6117 men and women in the study sample, the average heart age was 5.7 years higher than the chronological age, and 2631 (43%) adults had a predicted heart age ≥5 years older than their chronological age. Mean excess heart age increased with age (from 0.7 year among adults aged 30-39 to 11.2 years among adults aged 60-74) and body mass index (from 1.1 year among adults with normal weight to 11.8 years among adults with obesity). Non-Latino white women had the lowest mean excess heart age (2.3 years), and non-Latino black men and women had the highest excess heart age (8.4 years).

CONCLUSIONS

Racial/ethnic and sex disparities in CVD risk persist among adults in New York City. Use of heart age at the population level can support public awareness and inform targeted programs and interventions for population subgroups most at risk for CVD.

Relation of Sex and Race to Outcomes in Patients Undergoing Percutaneous Intervention With Drug-Eluting Stents

Cardiovascular disease is the leading cause of death in men and women, black and white. However, there exists limited outcomes data for women and blacks after percutaneous coronary intervention (PCI). The aim of this study was to evaluate the 1-year major cardiovascular events in patients who underwent PCI based on gender and race. We retrospectively analyzed data that were prospectively collected over 13 years at a large tertiary hospital in the United States. There were 12,050 patients who underwent PCI for both stable disease and acute coronary syndrome from 2003 to 2016. Of those, 1,952 were black men, 6,013 white men, 1,619 black women, and 2,466 white women. Major cardiovascular events at 1 year were assessed, and proportional Cox hazard model analyses were performed to assess outcome adjusted for confounding factors (i.e., age, body mass index, presentation with acute myocardial infarction, diabetes, smoking, history of coronary artery disease, family history of coronary artery disease, hyperlipidemia, hypertension, previous cardiovascular intervention, and chronic kidney disease). At 1 year, white men had significantly lower major cardiovascular events driven by lower rate of death compared with the other groups. Adjusted for confounders, major cardiovascular events were 1.3 to 1.5 times more likely to occur in black men and women and white women than in white men. There was a significant race by gender interaction (p <0.001).

Achieving Health Equity by Normalizing Cardiac Care

Purpose: It is well known that minority patients, and particularly African Americans undergo lower rates of cardiac procedures than the white population, even when covered by equivalent insurance.

Methods: We analyzed the rates of percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) and for intermediate coronary syndrome (ICS), and rates of transcatheter aortic valve replacement for aortic stenosis in the 2012–2013 Medicare Limited Data Set (5% sample) file.

Results: Although blacks have similar prevalence rates for AMI and ICS, they experience lower PTCA rates when compared with that of white patients (10.57 vs. 19.40, −46%). “Normalizing” procedure rates in the African American community to match their disease prevalence will require education and participation of all stakeholders: patients, providers, manufacturers, insurers, and advocacy organizations. Beyond improved clinical outcomes, financial incentives to “normalize care” exist. We estimate “lost” revenue within the Medicare population as a result of the lower procedure rates, at ∼$90 million annually ($22.0 million AMI, $9.4 million ICS and $68.7 million aortic valve disease).

Conclusions: Providing evidence-based care to all patients improves health equity and can lower downstream high-cost conditions such as heart failure and multiple repeat inpatient admissions. As we move toward value-based care, the opportunity to normalize treatment for everyone seeking care is within our data analytics, innovative and collective reach.

Gender and Race Disparities in Cardiovascular Disease Risk Factors among New York City Adults: New York City Health and Nutrition Examination Survey (NYC HANES) 2013-2014

While gender and racial/ethnic disparities in cardiovascular disease (CVD) risk factors have each been well characterized, few studies have comprehensively examined how patterns of major CVD risk factors vary and intersect across gender and major racial/ethnic groups, considered together. Using data from New York City Health and Nutrition Examination Survey 2013-2014-a population-based, cross-sectional survey of NYC residents ages 20 years and older-we measured prevalence of obesity, hypertension, hypercholesterolemia, smoking, and diabetes across gender and race/ethnicity groups for 1527 individuals. We used logistic regression with predicted marginal to estimate age-adjusted prevalence ratio by gender and race/ethnicity groups and assess for potential additive and multiplicative interaction. Overall, women had lower prevalence of CVD risk factors than men, with less hypertension (p = 0.040), lower triglycerides (p < 0.001), higher HDL (p < 0.001), and a greater likelihood of a heart healthy lifestyle, more likely not to smoke and to follow a healthy diet (p < 0.05). When further stratified by race/ethnicity, however, the female advantage was largely restricted to non-Latino white women. Non-Latino black women had significantly higher risk of being overweight or obese, having hypertension, and having diabetes than non-Latino white men or women, or than non-Latino black men (p < 0.05). Non-Latino black women also had higher total cholesterol compared to non-Latino black men (184.4 vs 170.5 mg/dL, p = 0.010). Despite efforts to improve cardiovascular health and narrow disparities, non-Latino black women continue to have a higher burden of CVD risk factors than other gender and racial/ethnic groups. This study highlights the importance of assessing for intersectionality between gender and race/ethnicity groups when examining CVD risk factors.

Racial Disparities in Patient Characteristics and Survival After Acute Myocardial Infarction

IMPORTANCE

Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI).

OBJECTIVE

To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018.

MAIN OUTCOMES AND MEASURES

Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates.

RESULTS

Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P < .001). Most categories of patient characteristics differed substantially between black patients and white patients. The cumulative propensity score discriminated race, with a C statistic of 0.89, and the propensity scores were associated with 1- and 5-year mortality rates (hazard ratio for the 75th percentile of the propensity score vs 25th percentile, 1.72; 95% CI, 1.43-2.08; P < .001). Patients in the lowest propensity score quintile associated with being a black individual (regardless of whether they were of white or black race) had a 5-year mortality rate of 15.5%, while those in the highest quintile had a 5-year mortality rate of 31.0% (P < .001). After adjusting for the propensity associated with being a black patient, there was no significant mortality rate difference by race (adjusted hazard ratio, 1.09; 95% CI, 0.93-1.26; P = .37) and no statistical interaction between race and propensity score (P = .42).

CONCLUSIONS AND RELEVANCE

Characteristics of black patients and white patients differed significantly at the time of admission for AMI. Those characteristics were associated with an approximately 3-fold difference in 5-year mortality rate following AMI and mediated most of the observed mortality rate difference between the races.

Clinical depression and anxiety among ST-elevation myocardial infarction hospitalizations: Results from Nationwide Inpatient Sample 2004-2013

Depression and anxiety are common among patients who have a major cardiovascular event. However, despite their frequency, there is a lack of evidence regarding the relationship between depression and/or anxiety and receiving revascularization in ST-elevation myocardial infarction (STEMI) hospitalizations. Using data from the Nationwide Inpatient Sample (NIS) from the years 2004 to 2013, we assessed whether a clinical co-diagnosis of depression and/or anxiety decreases the likelihood of revascularization among STEMI hospitalizations. Our central finding is that, paradoxically, the odds of in-hospital mortality were lower among STEMI hospitalizations with a clinical co-diagnosis of depression and/or anxiety as compared to those without. We further discovered that clinical diagnoses of depression and/or anxiety were less prevalent among revascularized as compared to non-revascularized STEMI hospitalizations. However, the percentage of clinical diagnoses of depression and/or anxiety among STEMI hospitalizations increased at a similar rate over a 10-year period irrespective of revascularization status. In conclusion, these results are suggestive of the potentially underdiagnosed mental health issues surrounding major cardiovascular events, and indeed, chronic disease as a whole. To our knowledge, this is the first study to document and examine the "depression paradox" among a population of cardiac patients.

Evidence for reduced susceptibility to cardiac bradycardias in South Asians compared with Caucasians

Objectives

To investigate ethnic differences in susceptibility to bradycardias in South Asian and white European patients in the UK by determining rates of permanent pacemaker (PPM) implantation for sinus node dysfunction (SND) and atrioventricular block (AVB) in each ethnic group.

Methods

We carried out a retrospective cohort study into new PPM implantation during the period from 1 May 2006 to 31 March 2014, in patients of South Asian and Caucasian ethnicity resident in Leicestershire, UK. Numbers of individuals at risk in each ethnic group were derived from UK National Census data of 2011. Crude, and age-standardised incidence rates and risk ratios per 1000 population of PPM implantation were calculated for Caucasians and South Asians.

Results

During the study period, 4883 individuals from the Leicestershire population of 980 328 underwent PPM implantation, a cumulative implantation rate of 4.98/1000 population. The population cumulative PPM implantation rate for SND was 1.74/1000, AVB 2.83/1000 and other indications 0.38/1000 population. The crude incidence in Caucasians (6.15/1000 population) was higher than in South Asians (1.07/1000 population) and remained higher after age standardisation (5.60/1000 vs 2.03/1000, P<0.001). The age-standardised cumulative PPM implantation rates were lower in South Asians for both SND (0.53/1000 in South Asians; 1.97/1000 in Caucasians, P<0.001) and AVB (1.30/1000 in South Asians; 3.17/1000 in Caucasians, P<0.001). Standardised risk ratios (95% CI) for PPM implantation in South Asians compared with Caucasians for all pacing indications, SND and AVB were 0.36 (95% CI 0.36 to 0.37), 0.27 (95% CI 0.27 to 0.28) and 0.41 (95% CI 0.41 to 0.42), respectively.

Conclusions

Rates of PPM implantation are lower in South Asians residing in the UK, compared with Caucasians. This observation raises the possibility of lower inherent susceptibility to bradycardias in South Asians compared with Caucasians. Studies aimed at identifying underlying mechanisms, including possible genetic differences, are warranted.

Randomized Controlled Trial of Group-Based Culturally Specific Cognitive Behavioral Therapy Among African American Smokers

Introduction

This study tested the efficacy of group-based culturally specific cognitive behavioral therapy (CBT) for smoking cessation among low-income African Americans.

Methods

Participants (N = 342; 63.8% male; M = 49.5 years old; M cigarettes per day = 18) were randomly assigned to eight sessions of group-based culturally specific or standard CBT, plus 8 weeks of transdermal nicotine patches. Biochemically verified 7-day point prevalence abstinence (ppa) was assessed at the end-of-therapy (ie, CBT) (EOT), and 3-, 6-, and 12-month follow-ups. Primary outcomes were the longitudinal intervention effect over the 12-month follow-up period, and 7-day ppa at the 6-month follow-up. Secondary outcomes included 7-day ppa at the EOT and 12-month follow-up, and intervention ratings. Generalized linear mixed modeling tested the longitudinal effect and logistic regression tested effects at specific timepoints.

Results

Generalized linear mixed modeling demonstrated a longitudinal effect of intervention condition. Specifically, 7-day ppa was two times (P = .02) greater following culturally specific CBT versus standard CBT when tested across all timepoints. Analyses by timepoint found no significant difference at 6 or 12 months, yet culturally specific CBT was efficacious at the EOT (62.5% vs. 51.5% abstinence, P = .05) and the 3-month follow-up (36.4% vs. 22.9% abstinence, P = .007). Finally, intervention ratings in both conditions were high, with no significant differences.

Conclusions

Culturally specific CBT had a positive longitudinal effect on smoking cessation compared to a standard approach; however, the effects were driven by short-term successes. We recommend the use of group-based culturally specific CBT in this population when possible, and future research on methods to prevent long-term relapse.

Implications

Culturally specific interventions are one approach to address smoking-related health disparities; however, evidence for their efficacy in African Americans is equivocal. Moreover, the methodological limitations of the existing literature preclude an answer to this fundamental question. We found a positive longitudinal effect of culturally specific CBT versus standard CBT for smoking cessation across the follow-up period. Analyses by assessment point revealed that the overall effect was driven by early successes. Best practices for treating tobacco use in this population should attend to ethnocultural factors, but when this is not possible, standard CBT is an alternative approach for facilitating long-term abstinence.

Ethnicity, Race, and Postoperative Stroke Risk Among 53,593 Patients with Asymptomatic Carotid Stenosis Undergoing Revascularization

BACKGROUND

The incidence of postoperative stroke after carotid endarterectomy is an uncommon event, and differences by racial and ethnic subgroups are not described fully in the literature.

OBJECTIVE

To investigate the impact of race and ethnicity on postoperative stroke risk among patients with asymptomatic carotid stenosis undergoing carotid endarterectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched for patients between the dates 2008 and 2015 to identify patients undergoing carotid endarterectomy with no history of stroke. Four racial and ethnic subgroups were included: non-Hispanic white, Hispanic white, non-Hispanic back, and non-Hispanic Asian. In addition to a descriptive statistical analysis, univariate and multivariate regression models were created to adjust for cardiovascular and perioperative risk factors and corrected for multiple comparisons.

RESULTS

Among the 53,593 patients identified meeting the inclusion criteria, 788 (1.45%) patients experienced a stroke within 30 days. The non-Hispanic white group compared with the minority subgroups had a lower risk of postoperative stroke (1.43% vs. 1.67%, P = 0.18). The greatest difference was between the non-Hispanic white and Hispanic white groups, but this was not significant on multivariable analysis (odds ratio 1.40, 95% confidence interval 0.97-2.02, P = 0.08) after adjustment for risk stroke factors. The strongest predictors of postoperative stroke were perioperative blood transfusion, dependent functional status, and longer operative time.

CONCLUSIONS

There was no difference between the racial and ethnic groups and the proportion of postoperative stroke among patients undergoing revascularization for asymptomatic carotid stenosis.

Racial/Ethnic Disparities in Quality of Care for Cardiovascular Disease in Ambulatory Settings: A Review

Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes.

A Tale of Two Patients: Patient-Centered Approaches to Adherence as a Gateway to Reducing Disparities

The disparate effects of social determinants of health on cardiovascular health status and health care have been extensively documented by epidemiology. Yet, very little attention has been paid to how understanding and addressing social determinants of health might improve the quality of clinical interactions, especially by improving patients' adherence to recommended therapies. We present a case and suggested approach to illustrate how cardiovascular clinicians can use patient-centered approaches to identify and address social determinants of health barriers to adherence and reduce the impact of unconscious clinician biases. We propose that cardiovascular clinicians (1) recognize that patients may have different belief systems about illnesses' cause and treatment, which may influence their actions, and not assume they share one's experiences or explanatory model; (2) Endeavor to understand the individual patient before you; (3) based on that understanding, tailor your approach to that individual. We suggest a previously-developed mnemonic for an approach to RESPECT the patient: First, show Respect; then elicit patients' understandings of their illness by asking about their Explanatory model. Ask about the patient's Social context, share Power in the interaction, show Empathy, ask about Concerns or fears, and work to develop Trust by building the relationship over time. We provide additional clinical resources to support these efforts, including lay descriptions of cardiovascular conditions, challenges to adherence, and suggested strategies to address them.

Smoking Cessation in Pulmonary Care Subjects: A Mixed Methods Analysis of Treatment-Seeking Participation and Preferences

BACKGROUND

African-American smokers experience disproportionate COPD morbidity. As a front-line COPD behavioral management strategy, smoking cessation is less prevalent among African-American smokers. Identifying barriers and predictors to smoking cessation in this population is important to bridging this disparity.

METHODS

In this study, the predictors of enrollment and attendance to a 3-session urban hospital smoking cessation program were examined. A retrospective chart review was conducted for all pulmonary clinic patients who smoked and were referred to the cessation program between June 2013 and May 2014. Demographic, smoking behavior, cardiopulmonary, and health status variables were extracted (N = 253). Second, a qualitative assessment of the beliefs and barriers for smoking cessation and physical activity were examined in a sub-sample of the population (n = 41).

RESULTS

One-hundred forty-seven of the pulmonary subjects (58%) enrolled in the cessation program, and 40 attended all sessions (16% of the total sample). Participants with COPD (odds ratio = 4.65, P = .030), or had a mother who had cancer (odds ratio = 4.49, P = .027), were more likely to attend the program. Qualitatively, pulmonary care patients who wanted to quit smoking and be more physically active cited: strong beliefs about the inability to engage in these behaviors, belief that quitting and increased activity might exacerbate poor health, and an inability to obtain pharmacotherapy as barriers to adopting these behaviors.

CONCLUSIONS

Smoking cessation program attendance in this sample of mostly African-American smokers was poor. Increased knowledge about cessation benefits and access to full-course pharmacotherapy, particularly in those without a COPD diagnosis and who do not have a maternal history of cancer, may be high-priority targets to promote cessation program uptake in this population. Increased knowledge and access to safe forms of physical activity may also be beneficial.

Racial and Ethnic Differences in Acute Coronary Syndrome and Myocardial Infarction Within the United States: From Demographics to Outcomes

In the United States, different races, ethnicities, and their subgroups experience disparities regarding acute coronary syndrome (ACS) and myocardial infarction (MI). This review highlights these differences across 4 stages that comprise the ACS/MI narrative: (1) patient demographics, (2) patient comorbidities and health risks, (3) treatments and their delays, and (4) outcomes. Overall, black and Hispanic ACS/MI patients are more likely to present with comorbidities, experience longer delays before treatment, and suffer worse outcomes when compared with non-Hispanic white patients. More specifically, across the studies analyzed, black and Hispanic ACS/MI patients were consistently more likely to be younger or female, or to have hypertension or diabetes, than non-Hispanic white patients. ACS/MI disparities also exist among Asian populations, and these are briefly outlined. However, black, Hispanic, and non-Hispanic white ACS/MI patients were the 3 most-studied racial and ethnic groups, indicating that additional studies of other minority groups, such as Native Americans, Asian populations, and black and Hispanic subgroups, are needed for their utility in reducing disparities. Despite notable improvement in ACS/MI treatment quality measures over recent decades, disparities persist. Causes are complex and extend beyond the healthcare system to culture and patients' personal characteristics; sophisticated solutions will be required. Continued research has the potential to further reduce or eliminate disparities in the comorbidities, delays, and treatments surrounding ACS and MI, extending healthy lifespans of many underserved and minority populations, while reducing healthcare costs.

Population-level differences in revascularization treatment and outcomes among various United States subpopulations

Despite recent general improvements in health care, significant disparities persist in the cardiovascular care of women and racial/ethnic minorities. This is true even when income, education level, and site of care are taken into consideration. Possible explanations for these disparities include socioeconomic considerations, elements of discrimination and racism that affect socioeconomic status, and access to adequate medical care. Coronary revascularization has become the accepted and recommended treatment for myocardial infarction (MI) today and is one of the most common major medical interventions in the United States, with more than 1 million procedures each year. This review discusses recent data on disparities in co-morbidities and presentation symptoms, care and access to medical resources, and outcomes in revascularization as treatment for acute coronary syndrome, looking especially at women and minority populations in the United States. The data show that revascularization is used less in both female and minority patients. We summarize recent data on disparities in co-morbidities and presentation symptoms related to MI; access to care, medical resources, and treatments; and outcomes in women, blacks, and Hispanics. The picture is complicated among the last group by the many Hispanic/Latino subgroups in the United States. Some differences in outcomes are partially explained by presentation symptoms and co-morbidities and external conditions such as local hospital capacity. Of particular note is the striking differential in both presentation co-morbidities and mortality rates seen in women, compared to men, especially in women ≤ 55 years of age. Surveillance data on other groups in the United States such as American Indians/Alaska Natives and the many Asian subpopulations show disparities in risk factors and co-morbidities, but revascularization as treatment for MI in these populations has not been adequately studied. Significant research is required to understand the extent of disparities in treatment in these subpopulations.

Reassessing the Usefulness of Coronary Artery Calcium Score among Varying Racial and Ethnic Groups by Geographic Locations: Relevance of the Korea Initiatives on Coronary Artery Calcification Registry

There is some disparity in the morbidity and mortality rates of cardiovascular disease (CVD) according to race, ethnicity, and geographic regions. Although prediction algorithms that evaluate risk of cardiovascular events have been established using traditional risk factors, they have also demonstrated a number of differences along with race and ethnicity. Of various risk assessment modalities, coronary artery calcium (CAC) score is a sensitive marker of calcific atherosclerosis and correlates well with atherosclerotic plaque burden. Although CAC score is now utilized as a useful tool for early detection of coronary artery disease, prior studies have suggested some variability in the presence and severity of coronary calcification according to race, ethnicity, and/or geographic regions. Among Asian populations, it would appear necessary to reappraise the utility of CAC score and whether it remains superior over and above established clinical risk prediction algorithms. To this end, the Korea initiatives on coronary artery calcification (KOICA) registry has been designed to identify the effectiveness of CAC score for primary prevention of CVD in asymptomatic Korean adults. This review discusses the important role of CAC score for prognostication, while also describing the design and rationale of the KOICA registry.