Contemporary treatment of heart failure: is there adequate evidence to support a unique strategy for African-Americans? Con position

Survival Association of Angiotensin Inhibitors in Heart Failure With Reduced Ejection Fraction: Comparisons Using Self-Identified Race and Genomic Ancestry

BACKGROUND

It remains unclear whether there is a racial disparity in the response to angiotensin inhibitors in patients with heart failure with reduced ejection fraction (HFrEF) and whether the role of genomic ancestry plays a part. Therefore, we compared survival rates associated with angiotensin inhibitors in patients with HFrEF by self-identified race and proportion of West African genomic ancestry.

METHODS

Three datasets totaling 1153 and 1480 self-identified Black and White patients, respectively, with HFrEF were meta-analyzed (random effects model) for race-based analyses. One dataset had genomic data for ancestry analyses (416 and 369 self-identified Black and White patients, respectively). Cox proportional hazards regression, adjusted for propensity scores, assessed the association of angiotensin inhibitor exposure with all-cause mortality by self-identified race or proportion of West African genomic ancestry.

RESULTS

In meta-analysis of self-identified race, adjusted hazard ratios (95% CI) for exposure to angiotensin inhibitors were similar in self-identified Black and White patients with HFrEF: 0.52 (0.31-0.85) P = 0.006 and 0.54 (0.42-0.71) P = 0.001, respectively. Results were similar when the proportion of West African genomic ancestry was > 80% or < 5%: 0.66 (0.34-1.25) P = 0.200 and 0.56 (0.26-1.23) P = 0.147, respectively.

CONCLUSIONS

Among self-identified Black and White patients with HFrEF, reduction in all-cause mortality associated with exposure to angiotensin inhibitors was similar regardless of self-identified race or proportion of West African genomic ancestry.

Acute heart failure in the African American patient

BACKGROUND

African Americans (AAs) are disproportionately affected by acute heart failure (AHF) compared with other racial/ethnic groups. Disparities in AHF risk factors among AAs are attributed to higher rates of hypertension and diabetes mellitus, lower socioeconomic status, higher dietary caloric and salt intake, and biologic/genetic differences. However, AAs are frequently underrepresented in AHF clinical trials, and race-related differences in risks and clinical outcomes are not well understood.

OBJECTIVE

The aim of this work was to review published data on AHF in the AA population, including management strategies that may differ based on race and common barriers to optimal care.

METHODS

Publications were identified in Pubmed (through June 10, 2013) with the use of the search strategy terms (acute heart failure) AND (black OR African American OR racial).

RESULTS

Racial disparities in the quality of AHF care are relatively uncommon; however, racial differences in pathophysiology have resulted in differing pharmacologic recommendations (eg, isosorbide dinitrate plus hydralazine is indicated only in AAs). Various socioeconomic factors influence disease progression, treatment compliance, and hospitalization/rehospitalization rates.

CONCLUSIONS

Further research would enhance understanding of pathophysiologic heart failure differences between racial groups. Programs are needed that incorporate known clinical and cultural differences to improve quality of care and reduce the disease burden of AHF for all patients.

The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults

AIMS

It is unknown whether sex differences in the association of diabetes with cardiovascular outcomes vary by race. We examined sex differences in the associations of diabetes with incident congestive heart failure (CHF) and coronary heart disease (CHD) between older black and white adults.

METHODS

We analyzed data from the Cardiovascular Health Study (CHS), a prospective cohort study of community-dwelling individuals aged ≥65 from four US counties. We included 4817 participants (476 black women, 279 black men, 2447 white women and 1625 white men). We estimated event rates and multivariate-adjusted hazard ratios for incident CHF, CHD, and all-cause mortality by Cox regression and competing risk analyses.

RESULTS

Over a median follow-up of 12.5years, diabetes was more strongly associated with CHF among black women (HR, 2.42 [95% CI, 1.70-3.40]) than black men (1.39 [0.83-2.34]); this finding did not reach statistical significance (P for interaction=0.08). Female sex conferred a higher risk for a composite outcome of CHF and CHD among black participants (2.44 [1.82-3.26]) vs. (1.44 [0.97-2.12]), P for interaction=0.03). There were no significant sex differences in the HRs associated with diabetes for CHF among whites, or for CHD or all-cause mortality among blacks or whites. The three-way interaction between sex, race, and diabetes on risk of cardiovascular outcomes was not significant (P=0.07).

CONCLUSIONS

Overall, sex did not modify the cardiovascular risk associated with diabetes among older black or white adults. However, our results suggest that a possible sex interaction among older blacks merits further study.

Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association

BACKGROUND

Heart failure (HF) is an important contributor to both the burden and cost of national healthcare expenditures, with more older Americans hospitalized for HF than for any other medical condition. With the aging of the population, the impact of HF is expected to increase substantially.

METHODS AND RESULTS

We estimated future costs of HF by adapting a methodology developed by the American Heart Association to project the epidemiology and future costs of HF from 2012 to 2030 without double counting the costs attributed to comorbid conditions. The model assumes that HF prevalence will remain constant by age, sex, and race/ethnicity and that rising costs and technological innovation will continue at the same rate. By 2030, >8 million people in the United States (1 in every 33) will have HF. Between 2012 and 2030, real (2010$) total direct medical costs of HF are projected to increase from $21 billion to $53 billion. Total costs, including indirect costs for HF, are estimated to increase from $31 billion in 2012 to $70 billion in 2030. If one assumes all costs of cardiac care for HF patients are attributable to HF (no cost attribution to comorbid conditions), the 2030 projected cost estimates of treating patients with HF will be 3-fold higher ($160 billion in direct costs).

CONCLUSIONS

The estimated prevalence and cost of care for HF will increase markedly because of aging of the population. Strategies to prevent HF and improve the efficiency of care are needed.

Effective strategies to improve the management of heart failure

The purpose of this article is to provide resources for primary care physicians to manage heart failure as a chronic disease. We review evidence-based interventions that can be adopted in primary care practices to improve adherence to available guidelines for medication use, promotion of self-care behaviors, transitions of care in acute decompensated heart failure, and end of life care. This information will be valuable to primary care providers who care for patients with heart failure in all care settings but is focused on the management of heart failure in the outpatient setting.

Disease management to promote blood pressure control among African Americans

African Americans have a higher prevalence of hypertension and poorer cardiovascular and renal outcomes than white Americans. The objective of this study was to determine whether a telephonic nurse disease management (DM) program designed for African Americans is more effective than a home monitoring program alone to increase blood pressure (BP) control among African Americans enrolled in a national health plan. A prospective randomized controlled study (March 2006-December 2007) was conducted, with 12 months of follow-up on each subject. A total of 5932 health plan members were randomly selected from the population of self-identified African Americans, age 23 and older, in health maintenance organization plans, with hypertension; 954 accepted, 638 completed initial assessment, and 485 completed follow-up assessment. The intervention consisted of telephonic nurse DM (intervention group) including educational materials, lifestyle and diet counseling, and home BP monitor vs. home BP monitor alone (control group). Measurements included proportion with BP < 120/80, mean systolic BP, mean diastolic BP, and frequency of BP self-monitoring. Results revealed that systolic BP was lower in the intervention group (adjusted means 123.6 vs. 126.7 mm Hg, P = 0.03); there was no difference for diastolic BP. The intervention group was 50% more likely to have BP in control (odds ratio [OR] = 1.50, 95% confidence interval [CI] 0.997-2.27, P = 0.052) and 46% more likely to monitor BP at least weekly (OR 1.46, 95% CI 1.07-2.00, P = 0.02) than the control group. A nurse DM program tailored for African Americans was effective at decreasing systolic BP and increasing the frequency of self-monitoring of BP to a greater extent than home monitoring alone. Recruitment and program completion rates could be improved for maximal impact.

Racial differences in reaching target low-density lipoprotein goal among individuals treated with prescription statin therapy

BACKGROUND

Studies indicate that, overall, African Americans are less likely to achieve control of hyperlipidemia compared with whites. No population-based studies have examined the effect of race on achieving target low-density lipoprotein (LDL) goals among treated individuals.

METHODS

Using computerized encounter and laboratory result data, we identified all African American and white patients in a Midwestern health system filling a statin prescription from January 1, 1997, through June 30, 2001 (index prescription), with no prescriptions filled 1 year before index prescription. We followed LDL results for 1 year after index prescription.

RESULTS

A total of 16052 new statin users (32.5% African American) were identified. Mean baseline LDL was higher for African Americans (170.2 +/- 36.6) than for whites (161.8 +/- 37.2) (P < .001). Whites were more adherent to therapy, with 48.6% of white patients exposed to statins >80% of follow-up time (31.2% of African Americans) (P < .001). By the end of follow-up, 49.5% of African Americans and 71.1% of whites reached LDL goal. A proportional hazards model adjusting for age, sex, median household income, physician specialty, clinic site, baseline LDL, starting dose, and target LDL indicated that African Americans were less likely to reach goal compared with whites (hazard ratio 0.64, 95% CI 0.61-0.68). Results persisted after controlling for racial differences in statin adherence and LDL testing (hazard ratio 0.60, 95% CI 0.57-0.63).

CONCLUSIONS

African American patients initiating statin therapy are less likely to achieve LDL goal, even after controlling for adherence differences and other factors, suggesting that African Americans may require different pharmacologic management.

Race and renal impairment in heart failure: mortality in blacks versus whites

BACKGROUND

Renal impairment is an emerging prognostic indicator in heart failure (HF) patients. Despite known racial differences in the progression of both HF and renal disease, it is unclear whether the prognosis for renal impairment in HF patients differs by race. We sought to determine in HF patients the 1-year mortality risks associated with elevated creatinine and impaired estimated glomerular filtration rate (eGFR) and to quantify racial differences in mortality.

METHODS AND RESULTS

We retrospectively evaluated the National Heart Care Project nationally representative cohort of 53,640 Medicare patients hospitalized with HF. Among 5669 black patients, mean creatinine was 1.6+/-0.9 mg/dL, and 54% had an eGFR < or =60, compared with creatinine 1.5+/-0.7 mg/dL and 68% eGFR < or =60 in 47,971 white patients. Higher creatinine predicted increased mortality risk, although the magnitude of risk differed by race (interaction P=0.0001). Every increase in creatinine of 0.5 mg/dL was associated with a >10% increased risk in adjusted mortality for blacks, compared with >15% increased risk in whites (interaction P=0.0001), with the most striking racial disparities at the highest levels of renal impairment. Depressed eGFR showed similar racial differences (interaction P=0.0001).

CONCLUSIONS

Impaired renal function predicts increased mortality in elderly HF patients, although risks are more pronounced in whites. Distinct morbidity and mortality burdens in black versus white patients underscore the importance of improving patient risk-stratification, defining optimal therapies, and exploring physiological underpinnings of racial differences.