Racial variations in quality of care and outcomes in an ambulatory heart failure cohort

Artificial intelligence approaches for phenotyping heart failure in U.S. Veterans Health Administration electronic health record

AIMS

Heart failure (HF) is a clinical syndrome with no definitive diagnostic tests. HF registries are often based on manual reviews of medical records of hospitalized HF patients identified using International Classification of Diseases (ICD) codes. However, most HF patients are not hospitalized, and manual review of big electronic health record (EHR) data is not practical. The US Department of Veterans Affairs (VA) has the largest integrated healthcare system in the nation, and an estimated 1.5 million patients have ICD codes for HF (HF ICD-code universe) in their VA EHR. The objective of our study was to develop artificial intelligence (AI) models to phenotype HF in these patients.

METHODS AND RESULTS

The model development cohort (n = 20 000: training, 16 000; validation 2000; testing, 2000) included 10 000 patients with HF and 10 000 without HF who were matched by age, sex, race, inpatient/outpatient status, hospital, and encounter date (within 60 days). HF status was ascertained by manual chart reviews in VA's External Peer Review Program for HF (EPRP-HF) and non-HF status was ascertained by the absence of ICD codes for HF in VA EHR. Two clinicians annotated 1000 random snippets with HF-related keywords and labelled 436 as HF, which was then used to train and test a natural language processing (NLP) model to classify HF (positive predictive value or PPV, 0.81; sensitivity, 0.77). A machine learning (ML) model using linear support vector machine architecture was trained and tested to classify HF using EPRP-HF as cases (PPV, 0.86; sensitivity, 0.86). From the 'HF ICD-code universe', we randomly selected 200 patients (gold standard cohort) and two clinicians manually adjudicated HF (gold standard HF) in 145 of those patients by chart reviews. We calculated NLP, ML, and NLP + ML scores and used weighted F scores to derive their optimal threshold values for HF classification, which resulted in PPVs of 0.83, 0.77, and 0.85 and sensitivities of 0.86, 0.88, and 0.83, respectively. HF patients classified by the NLP + ML model were characteristically and prognostically similar to those with gold standard HF. All three models performed better than ICD code approaches: one principal hospital discharge diagnosis code for HF (PPV, 0.97; sensitivity, 0.21) or two primary outpatient encounter diagnosis codes for HF (PPV, 0.88; sensitivity, 0.54).

CONCLUSIONS

These findings suggest that NLP and ML models are efficient AI tools to phenotype HF in big EHR data to create contemporary HF registries for clinical studies of effectiveness, quality improvement, and hypothesis generation.

The RightSTEPS initiative: Continuing education impact on clinicians' optimal medical therapy practices for chronic heart failure

PURPOSE

Despite the existence of expert recommendations that can improve morbidity and mortality, reduce the need for hospitalization or readmission, and enhance quality of life in patients with heart failure (HF), many patients do not receive optimal medical therapy (OMT). The goal of this initiative, titled RightSTEPS, was to help physicians take the right steps to apply-evidence-based HF management strategies in clinical practice.

METHODS

Using the PRECEDE-PROCEED Model aimed at improving the clinical behavior of the learner, the instructional design featured 23 online and live face-to-face activities offering up to 16 credit hours of CME/CNE credit. These activities were delivered sequentially in three phases: predisposing, enabling and reinforcing. The lessons provided concise, pragmatic, stepwise management strategies aimed at empowering clinicians to prescribe evidence-based, guideline-directed OMT for patients with HF.

RESULTS

The predisposing and reinforcing online activities within the initiative reached a total of 71,510 learners with 23,902 successfully completed activities and post-tests; the enabling face-to-face activities reached a total audience of 763 clinicians. This initiative resulted in a statistically significant (p < 0.0001) increase in knowledge and competence related to HF OMT among the clinician learners. Furthermore, follow-up surveys indicated a commitment from learners to implement these guideline-directed strategies in their clinical practice.

CONCLUSIONS

This initiative demonstrated that the design of the RightSTEPS curriculum, using the Precede-Proceed model with sequentially-delivered, blended learning, provides a methodological framework to help learners translate knowledge into improvements in clinical behavior with the potential to improve patient health outcomes.

Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program

IMPORTANCE

Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients.

OBJECTIVE

To compare performance in the PVBM Program by practice characteristics.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013.

EXPOSURES

High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries).

MAIN OUTCOMES AND MEASURES

Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs.

RESULTS

Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P < .001 across groups). Practices categorized as high social risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next best cost score (z score, -0.18 [95% CI, -0.25 to -0.10]), then high medical and social risk (z score, 0.40 [95% CI, 0.23 to 0.57]), and then high medical risk only (z score, 0.82 [95% CI, 0.65 to 0.99]) (P < .001 across groups). Total per capita costs were $9506 for practices categorized as low risk, $13 683 for high medical risk only, $8214 for high social risk only, and $11 692 for high medical and social risk. These patterns were associated with fewer bonuses and more penalties for high-risk practices.

CONCLUSIONS AND RELEVANCE

During the first year of the Medicare Physician Value-Based Payment Modifier Program, physician practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.

Self-Care Behaviors of African Americans Living with Heart Failure

African Americans have a higher risk of developing heart failure (HF) than persons from other ethnic groups. Once diagnosed, they have lower rates of HF self-care and poorer health outcomes. Promoting engagement in HF self-care is amenable to change and represents an important way to improve the health of African Americans with HF. This study used a community-based participatory action research methodology called photovoice to explore the practice of HF self-care among low-income, urban, community dwelling African Americans. Using the photovoice methodology, themes emerged regarding self-care management and self-care maintenance.

Cause-Specific Deaths in Non-Dialysis-Dependent CKD

CKD is associated with higher risk of death, but details regarding differences in cause-specific death in CKD are unclear. We examined the leading causes of death among a non-dialysis-dependent CKD population using an electronic medical record-based CKD registry in a large healthcare system and the Ohio Department of Health mortality files. We included 33,478 white and 5042 black patients with CKD who resided in Ohio between January 2005 and September 2009 and had two measurements of eGFR<60 ml/min per 1.73 m(2) obtained 90 days apart. Causes of death (before ESRD) were classified into cardiovascular, malignancy, and non-cardiovascular/non-malignancy diseases and non-disease-related causes. During a median follow-up of 2.3 years, 6661 of 38,520 patients (17%) with CKD died. Cardiovascular diseases (34.7%) and malignant neoplasms (31.8%) were the leading causes of death, with malignancy-related deaths more common among those with earlier stages of kidney disease. After adjusting for covariates, each 5 ml/min per 1.73 m(2) decline in eGFR was associated with higher risk of death due to cardiovascular disease (hazard ratio [HR], 1.10; 95% confidence interval [95% CI], 1.08 to 1.12) and non-cardiovascular/non-malignancy diseases (HR, 1.12; 95% CI, 1.09 to 1.14) but not to malignancy. In the adjusted models, blacks had overall-mortality hazard ratios similar to those of whites but higher hazard ratios for cardiovascular deaths. Further studies to confirm these findings and explain the mechanisms for differences are warranted. In addition to lowering cardiovascular burden in CKD, efforts to target known risk factors for cancer at the population level are needed.

Association between process quality measures for heart failure and mortality among US veterans

BACKGROUND

The few available studies of the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting (IQR) care process indicators have not linked receipt of recommended care processes in heart failure (HF) with lower mortality. Because the Veterans Health Administration (VHA) also tracks hospital inpatient quality reporting indicators, in addition to VHA-specific inpatient (pneumococcal and influenza vaccination) and outpatient (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin receptor blocker [ARB] use for left ventricular [LV] dysfunction and LV function documentation) care process indicators, we examined the association between receipt of these care processes and 30-day and 1-year mortality.

METHODS

Retrospective study of 107,045 patients with HF treated at 128 VHA hospitals between 2001 and 2007 and followed up through 2008. We assessed the relationship between receipt of each HF care process and death at 30 days (inpatients only) and 1 year (all patients), using generalized estimating equations to adjust for clinical characteristics and clustering within hospitals.

RESULTS

Overall, inpatient/outpatient use of ACEI/ARB and receipt of pneumococcal or influenza vaccinations were related to lower risks of 30-day and/or 1-year mortality (adjusted odds ratios 0.51-0.77 for vaccinations and 0.60-0.78 for ACEI/ARB use). Conversely, discharge instructions, inpatient/outpatient LV function assessment, or weight instructions before admission were either not related or related to a slightly increase in mortality. Stratified analyses by various mortality risk subgroups did not reveal discernable "dose-response" relationship between mortality risk stratification and the association of care process and mortality.

CONCLUSIONS

Receipt of care processes related to recommended medications and vaccinations were associated with lower 30-day and/or 1-year risk-adjusted mortality in patients with HF. Receipt of care processes that assess patient counseling or chart documentation was not related to lower mortality.

Prognostic significance of hyponatremia among ambulatory patients with heart failure and preserved and reduced ejection fractions

Hyponatremia in heart failure (HF) is an established predictor of adverse outcomes in hospitalized patients with reduced ejection fraction (EF). However, there is a paucity of data in ambulatory patients with HF with preserved ejection fraction (HFpEF). We examined the prevalence, risk factors, and long-term outcomes of hyponatremia (serum sodium ≤135 mEq/L) in ambulatory HFpEF and HF with reduced EF (HFrEF) in a national cohort of 8,862 veterans treated in Veterans Affairs clinics. Multivariable logistic regression models were used to identify factors associated with hyponatremia, and multivariable Cox proportional hazard models were used for analysis of outcomes. The cohort consisted of 6,185 patients with HFrEF and 2,704 patients with HFpEF with a 2-year follow-up. Hyponatremia was present in 13.8% and 12.9% patients in HFrEF and HFpEF, respectively. Hyponatremia was independently associated with younger age, diabetes, lower systolic blood pressure, anemia, body mass index <30 kg/m(2), and spironolactone use, whereas African-American race and statins were inversely associated. In multivariate analysis, hyponatremia remained a significant predictor of all-cause mortality in both HFrEF (hazards ratio [HR] 1.26, 95% confidence interval [CI] 1.11 to 1.44, p <0.001) and HFpEF (HR 1.40, 95% CI 1.12 to 1.75, p = 0.004) and a significant predictor of all-cause hospitalization in patients with HFrEF (HR 1.18, 95% CI 1.07 to 1.31, p = 0.001) but not in HFpEF (HR 1.08, 95% CI 0.92 to 1.27, p = 0.33). In conclusion, hyponatremia is prevalent at a similar frequency of over 10% in ambulatory patients with HFpEF and HFrEF. Hyponatremia is an independent prognostic marker of mortality across the spectrum of patients with HFpEF and HFrEF. In contrast, it is an independent predictor for hospitalization in patients with HFrEF but not in patients with HFpEF.

Go to the hospital or stay at home? A qualitative study of expected hospital decision making among older African Americans with advanced heart failure

To address the need for more information concerning hospital decision making, we conducted in-depth interviews among African Americans with heart failure and their family caregivers (n = 11 dyads). Using a case scenario, we asked participants about their anticipated hospitalization decisions. Most patients indicated that they would seek care to avoid further deterioration or death from their worsening condition. Many family caregivers anticipated having an active influence on hospitalization decisions. Findings suggest that social workers should encourage the development of adequate home-based services, recognize diverse communication styles, and use this information to facilitate medical decision making by these patients and their caregivers.

Who enrolls in the Medicare Part D prescription drug benefit program? Medication use among patients with heart failure

Background

Dispensing data from Medicare Part D standalone prescription drug plans are now available, but characteristics of enrollees with heart failure have not been well described.

Methods and Results

We identified 81 874 patients with prevalent heart failure as of January 1, 2010, in a nationally representative 5% sample of Medicare beneficiaries. We classified patients according to enrollment in a Medicare Part D plan as of January 1, 2010. Demographic characteristics, comorbid conditions, and prescriptions were compared by enrollment status. A total of 49 252 (60.2%) were enrolled in a Medicare Part D plan as of January 1. Enrollees were more often women, black, and of lower socioeconomic status. Enrollees with heart failure more often filled prescriptions for loop diuretics than angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, β‐blockers, or aldosterone antagonists. During the first 4 months of 2010, 5444 (12.3%) reached the coverage gap, and 566 (1.3%) required catastrophic coverage beyond the gap.

Conclusions

Medicare beneficiaries with heart failure differ significantly according to enrollment in Part D prescription drug plans and represent a population underrepresented in clinical efficacy trials. Many face the coverage gap, and few select Medicare Part D plans that provide coverage during the gap. Linking Medicare Part D event data with clinical registries could help to determine whether eligible enrollees are undertreated for heart failure.

Low literacy is associated with increased risk of hospitalization and death among individuals with heart failure

BACKGROUND

Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied.

METHODS

We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy.

RESULTS

Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization.

CONCLUSIONS

Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted.

Atrial Fibrillation and Race - A Contemporary Review

Atrial fibrillation (AF) is the most commonly encountered clinical arrhythmia and is associated with adverse outcomes and increased healthcare costs. Racial variations in AF are recognized yet poorly understood. In this review we summarize racial differences in AF epidemiology, risk factors, genetics, and outcomes. We identify novel risk factors, inflammatory mediators and biomarkers associated with AF, which have had limited study in racial and ethnic minorities. We describe the mismatch between risk factor burden and AF. We highlight the limited participation of minorities in trials for AF management and stroke prevention that contrasts with observed racial variability in anticoagulation efficacy and practice. Throughout we provide specific strategies for future directions to address gaps in the epidemiology of racial differences and to meet identified racial disparities. We specifically identify areas for further research. We conclude that addressing disparities in prevention and healthcare resource allocation will likely improve AF-related outcomes in minorities.

Heart failure in North America

Heart failure is a major health problem that affects patients and healthcare systems worldwide. Within the continent of North America, differences in economic development, genetic susceptibility, cultural practices, and trends in risk factors and treatment all contribute to both inter-continental and within-continent differences in heart failure. The United States and Canada represent industrialized countries with similar culture, geography, and advanced economies and infrastructure. During the epidemiologic transition from rural to industrial in countries such as the United States and Canada, nutritional deficiencies and infectious diseases made way for degenerative diseases such as cardiovascular diseases, cancer, overweight/obesity, and diabetes. This in turn has resulted in an increase in heart failure incidence in these countries, especially as overall life expectancy increases. Mexico, on the other hand, has a less developed economy and infrastructure, and has a wide distribution in the level of urbanization as it becomes more industrialized. Mexico is under a period of epidemiologic transition and the etiology and incidence of heart failure is rapidly changing. Ethnic differences within the populations of the United States and Canada highlight the changing demographics of each country as well as potential disparities in heart failure care. Heart failure with preserved ejection fraction makes up approximately half of all hospital admissions throughout North America; however, important differences in demographics and etiology exist between countries. Similarly, acute heart failure etiology, severity, and management differ between countries in North America. The overall economic burden of heart failure continues to be large and growing worldwide, with each country managing this burden differently. Understanding the inter-and within-continental differences may help improve understanding of the heart failure epidemic, and may aid healthcare systems in delivering better heart failure prevention and treatment.

Heart failure with preserved ejection fraction in African Americans: The ARIC (Atherosclerosis Risk In Communities) study

OBJECTIVES

In an entirely African-American cohort, we compared clinical characteristics, cardiac structure and function, and all-cause mortality in patients with heart failure (HF) with preserved ejection fraction (HFpEF) in relation to patients with heart failure with reduced ejection fraction (HFrEF) and those without HF.

BACKGROUND

African Americans are at increased risk for HF. Nevertheless, there are limited phenotypic and prognostic data in African Americans with HFpEF compared with those with HFrEF and those without HF.

METHODS

Middle-aged African Americans from the Jackson, Mississippi, cohort of the ARIC (Atherosclerosis Risk In Communities) study (n = 2,445) underwent echocardiography between 1993 and 1995. HF prevalence was available in 1,962 patients for whom left ventricular ejection fraction (LVEF) could be quantified. Participants with HF were categorized as having HFpEF (LVEF ≥50%), HFrEF (LVEF <50%), or no HF, with comparisons made between groups.

RESULTS

HF was identified in 116 (5.9%) participants (HFpEF n = 85 [73%]; HFrEF n = 31 [27%]). Compared with those without HF, those with HFpEF were older, were more likely to be female, and had more frequent comorbidities and concentric hypertrophy. In relation to HFrEF, those with HFpEF were more likely to be female but less likely to have coronary heart disease, diabetes mellitus, chronic kidney disease, left atrial enlargement, and eccentric hypertrophy. Over a median 13.7 years of follow-up, risk of death differed between groups, with age- and sex-adjusted hazard ratios of 1.51 (95% confidence interval: 1.01 to 2.25) for HFpEF versus those without HF and 2.50 (95% confidence interval: 1.37 to 4.58) for HFrEF versus HFpEF.

CONCLUSIONS

In this cohort of middle-aged African Americans, HFpEF was the most common form of HF and was associated with a substantially better prognosis than HFrEF but worse than those without HF.

Secular trends in the etiology and comorbidity of hospitalized patients with congestive heart failure: A single-center retrospective study

Objective

To assess the secular trends in the etiology and comorbidity of patients hospitalized with congestive heart failure (CHF).

Methods

Data of 7,319 patients (mean age 59.6 years, 62.1% male) with a primary discharge diagnosis of CHF, hospitalized from January 1, 1993 to December 31, 2007 at the Chinese People's Liberation Army (PLA) General Hospital were extracted and analyzed. These patients were divided into three groups according to hospitalization period: 1993–1997 (n = 1623), 1998–2002 (n = 2444), and 2003–2007 (n = 3252). The etiological characteristics and comorbidities were assessed.

Results

Over the study period, the proportion of patients with ischemic heart disease (IHD) increased from 37.2% during the period 1993–1997 to 46.8% during the period 2003–2007, while that with valvular heart disease (VHD) decreased from 35.2% during the period 1993–1997 to 16.6% during the period 2003–2007 (both P < 0.05). Atrial fibrillation (AF) was the most common comorbidity of heart failure (23.2%, 23.0% and 20.6%, respectively, in the three periods). Compared to that of the period of 1993–1997 with that of, the proportion of patients with myocardial infarction, pneumonia, renal function impairment and hepatic cirrhosis of the period of 2003–2007 increased significantly (P < 0.05) and the proportion of patients with chronic obstructive pulmonary disease and atrial fibrillation decreased significantly (P < 0.05).

Conclusions

This study implies that IHD has became a more common etiology of CHF, while VHD has deceased as an etiology of CHF in Chinese patients during the last two decades.

Social support among African Americans with heart failure: is there a role for community health advisors?

OBJECTIVE

The study had 2 objectives: (1) to gather the observations of community health advisors (CHAs) on the role of social support in the lives of African Americans; and (2) to develop a lay support intervention framework, on the basis of the existing literature and observations of CHAs, depicting how social support may address the needs of African American patients with heart failure.

METHODS

Qualitative data were collected in semistructured interviews among 15 CHAs working in African American communities in Birmingham, Alabama.

RESULTS

Prominent themes included the challenge of meeting clients' overlapping health care and general life needs, the variation in social support received from family and friends, and the opportunities for CHAs to provide multiple types of social support to clients. CHAs also believed that their support activities could be implemented among populations with heart failure.

CONCLUSION

The experience of CHAs with social support can inform a potential framework of a lay support intervention among African Americans with heart failure.

Impact of noncardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction

OBJECTIVES

The aim of this study was to evaluate the prevalence and prognostic impacts of noncardiac comorbidities in patients with heart failure (HF) with preserved ejection fraction (HFpEF) compared with those with HF with reduced ejection fraction (HFrEF).

BACKGROUND

There is a paucity of information on the comparative prognostic significance of comorbidities between patients with HFpEF and those with HFrEF.

METHODS

In a national ambulatory cohort of veterans with HF, the comorbidity burden of 15 noncardiac comorbidities and the impacts of these comorbidities on hospitalization and mortality were compared between patients with HFpEF and those with HFrEF.

RESULTS

The cohort consisted of 2,843 patients with HFpEF and 6,599 with HFrEF with 2-year follow-up. Compared with patients with HFrEF, those with HFpEF were older and had higher prevalence of chronic obstructive pulmonary disease, diabetes, hypertension, psychiatric disorders, anemia, obesity, peptic ulcer disease, and cancer but a lower prevalence of chronic kidney disease. Patients with HFpEF had lower HF hospitalization, higher non-HF hospitalization, and similar overall hospitalization compared with those with HFrEF (p < 0.001, p < 0.001, and p = 0.19, respectively). An Increasing number of noncardiac comorbidities was associated with a higher risk for all-cause admissions (p < 0.001). Comorbidities had similar impacts on mortality in patients with HFpEF compared with those with HFrEF, except for chronic obstructive pulmonary disease, which was associated with a higher hazard (1.62 [95% confidence interval: 1.36 to 1.92] vs. 1.23 [95% confidence interval: 1.11 to 1.37], respectively, p = 0.01 for interaction) in patients with HFpEF.

CONCLUSIONS

There is a higher noncardiac comorbidity burden associated with higher non-HF hospitalizations in patients with HFpEF compared with those with HFrEF. However, individually, most comorbidities have similar impacts on mortality in both groups. Aggressive management of comorbidities may have an overall greater prognostic impact in HFpEF compared to HFrEF.

Similarities and Differences of Self-Care Behaviors Between Korean Americans and Caucasian Americans With Heart Failure

Purpose:

To compare the differences of self-care behaviors between Korean Americans with heart failure (HF) and Caucasian Americans with HF.

Method:

Ninety ( N = 90) participants (45 Korean Americans and 45 Caucasian Americans) were recruited for this study. A two-group, comparative, descriptive design using the Revised Heart Failure Self-Care Behavior Scale was used to assess self-care behaviors.

Results:

Self-care behavior was not significantly different between the two groups ( p > .05). However, culture-specific self-care behaviors were evident between two racial groups.

Discussion:

Implementation of culturally congruent education programs could be useful in preventing and managing HF. Further studies comparing self-care behaviors should be conducted in diverse racial populations.

Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction

BACKGROUND

Hispanics are the fastest growing segment of the US population and have a higher prevalence of cardiovascular risk factors than non-Hispanic whites. However, little is known about whether elderly Hispanics have higher readmission rates for heart failure (HF) and acute myocardial infarction (AMI) than whites and whether this is due to site of care.

METHODS

We examined hospitalizations for Medicare patients with a primary discharge diagnosis of HF and AMI in 2006 to 2008. We categorized hospitals in the top decile of proportion of Hispanic patients as "Hispanic serving" and used logistic regression to examine the relationship between patient ethnicity, hospital Hispanic-serving status, and readmissions.

RESULTS

Hispanic patients had higher risk-adjusted readmission rates than whites for both HF (27.9% vs 25.9%, odds ratio [OR] 1.11, 95% CI 1.07-1.14, P < .001) and AMI (23.0% vs 21.0%, OR 1.12, 95% CI 1.07-1.18, P < .001). Similarly, Hispanic-serving hospitals had higher readmission rates than non-Hispanic-serving hospitals for both HF (27.4% vs 25.8%, OR 1.09, 95% CI 1.06-1.12, P < .001) and AMI (23.0% vs 20.8%, OR 1.13, 95% CI 1.09-1.18, P < .001). In analyses considering ethnicity and site of care simultaneously, both Hispanics and whites had higher readmission rates at Hispanic-serving hospitals.

CONCLUSIONS

Elderly Hispanic patients are more likely to be readmitted for HF and AMI than whites, partly due to the hospitals where they receive care. Our findings suggest that targeting the site of care and these high-risk patients themselves will be necessary to reduce disparities in readmissions for this growing group of patients.

Rurality and event-free survival in patients with heart failure

BACKGROUND

Evidence of health disparities between urban and rural populations usually favors urban dwellers. The impact of rurality on heart failure (HF) outcomes is unknown.

OBJECTIVE

We compared event-free survival between HF patients living in urban and rural areas.

METHODS

In this longitudinal study, 136 patients with HF (male, 70%; age, mean ± SD 61 ± 11 years; New York Heart Association class III/IV, 60%) were enrolled. Patients' emergency department visits for HF exacerbation and rehospitalization during follow-up were identified. Rural status was determined by rural-urban commuting area code. Survival analysis was used to determine the effect of rurality on outcomes while controlling for relevant demographic, clinical, and psychosocial variables.

RESULTS

Rural patients (64%) had longer event-free survival than urban patients (P = .015). Rurality (P = .04) predicted event-free survival after controlling for age, marital status, New York Heart Association class, medications, adherence to medications, depressive symptoms, and social support.

CONCLUSIONS

Rural patients were less likely than their urban counterparts to experience an event. Further research is needed to identify protective factors that may be unique to rural settings.

Association of systolic blood pressure with mortality in patients with heart failure with reduced ejection fraction: a complex relationship

BACKGROUND

In ambulatory patients with heart failure with reduced ejection fraction (HFrEF), high systolic blood pressure (SBP) is associated with better outcomes. However, it is not known whether there is a ceiling beyond which high SBP has a detrimental effect. Thus, our aim was to assess the linearity of association between SBP and mortality.

METHODS

We used the External Peer Review Program (EPRP) and Digitalis Investigation Group (DIG) trial databases of HFrEF patients. Linearity of association of SBP with mortality was assessed by plotting Martingale residuals against SBP. To assess the patterns of relationship of SBP with mortality, we used restricted cubic spline analysis with Cox proportional hazards model.

RESULTS

In patients with mild-to-moderate left ventricular systolic dysfunction (LVSD) (30% ≤ LVEF < 50%), SBP had a nonlinear association with mortality in both EPRP (n = 3,693) and DIG (n = 3,263) databases. In these patients, SBP had a significant U-shaped association with mortality in EPRP and a trend toward U-shaped relationship in DIG database. In patients with severe LVSD (LVEF <30%), SBP had a linear association with mortality in both EPRP (n = 2,906) and DIG (n = 3,537) databases, with lower SBP being associated with increased mortality.

CONCLUSIONS

Systolic blood pressure has a complex nonlinear association with mortality in patients with heart failure. Whereas it has a U-shaped association in patients with mild-to-moderate LVSD, it has a linear association with mortality in patients with severe LVSD. Recognition of this pattern of association of blood pressure profile may help clinicians in providing better care for their patients and help improve existing prediction models.

Racial and ethnic differences in subclinical myocardial function: the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Racial/ethnic differences in the incidence and severity of heart failure (HF) are not well understood, but may be related to pre-existing variations in myocardial function.

OBJECTIVE

To examine racial/ethnic differences in regional myocardial function among asymptomatic individuals free of known cardiovascular disease.

DESIGN, SETTING AND PATIENTS

The Multi-Ethnic Study of Atherosclerosis is a prospective, observational study of individuals without baseline cardiovascular disease, representing four major racial/ethnic groups. A total of 1099 study participants underwent cardiac MRI with tissue tagging; for each study, peak systolic strain (Ecc) and strain rate (SRs) were determined in four left ventricular (LV) regions.

MAIN OUTCOME MEASURES

Multiple linear regression was used to analyse the relationship between race/ethnicity and regional strain (Ecc and SRs) while adjusting for cardiovascular risk factors.

RESULTS

Compared with other racial/ethnic groups, Chinese-Americans had the greatest magnitude of Ecc in a majority of LV regions (-19.60±3.78, p<0.05); Chinese-Americans also had the greatest absolute values for SRs in all regions, reflecting higher rate of systolic contraction (-2.01±0.76, p<0.05). Conversely, African-Americans had the lowest Ecc values (-17.50±4.00, p<0.05) in the majority of wall regions while Hispanics demonstrated the lowest rate of contractility in all wall regions (-1.44±0.50, p≤0.001) in comparison with the other racial/ethnic groups. These race-based differences remained significant in the majority of LV wall regions after adjusting for multiple variables, including hypertension and LV mass.

CONCLUSIONS

Important race-based differences in regional LV systolic function in a large cohort of asymptomatic individuals have been demonstrated. Further research is needed to investigate the possible mechanisms related to the race/ethnicity-based variations found in this study.

Metformin use and mortality in ambulatory patients with diabetes and heart failure

BACKGROUND

Despite the common coexistence of diabetes and heart failure (HF), the optimal medial treatment of diabetes in HF patients has not been well studied. We sought to compare the association between metformin use and clinical outcomes in a cohort of ambulatory patients with diabetes and established HF.

METHODS AND RESULTS

Using propensity score-matched samples, we examined the association between metformin use and the risk of death or risk of hospitalization in a national cohort of 6185 patients with HF and diabetes treated in ambulatory clinics at Veteran Affairs medical centers. In this cohort, 1561 (25.2%) patients were treated with metformin. At 2 years of follow-up, death occurred in 246 (15.8%) patients receiving metformin and in 1177 (25.5%) patients not receiving metformin (P<0.001). In the propensity score-matched analysis (n=2874), death occurred in 232 (16.1%) patients receiving metformin compared with 285 (19.8%) patients not receiving metformin (hazard ratio, 0.76; 95% confidence interval, 0.63 to 0.92; P<0.01). In propensity score-matched analyses, HF hospitalization or total hospitalization rates were not significantly different between individuals treated with metformin compared with those not treated with metformin (hazard ratio, 0.93; 95% confidence interval, 0.74 to 1.18; and hazard ratio, 0.94; 95% confidence interval, 0.83 to 1.07, respectively).

CONCLUSIONS

Metformin therapy was associated with lower rates of mortality in ambulatory patients with diabetes and HF. Future prospective studies are necessary to define the optimal therapy for diabetic patients with HF.

Comparison across races of peak oxygen consumption and heart failure survival score for selection for cardiac transplantation

The aim of the present study was to determine whether peak oxygen consumption (VO(2)) and the Heart Failure Survival Score (HFSS) predict prognosis in European-American, African-American, and Hispanic-American patients with chronic heart failure referred for heart transplantation. The peak VO(2) and the HFSS have previously been shown to effectively risk stratify patients with chronic heart failure and are criteria for the listing for heart transplantation. However, the effect of race on the predictive value of these variables has not been studied. A total of 715 patients with congestive heart failure (433 European American, 126 African American, 123 Hispanic American, and 33 other), who had been referred for heart transplantation, underwent cardiopulmonary exercise testing with measurement of the peak VO(2) and calculation of the HFSS. A total of 354 patients had died or undergone urgent heart transplantation or implantation of a left ventricular assist device during the 962 +/- 912 days of follow-up. On univariate and multivariate Cox hazard analysis, both peak VO(2) and the HFSS were powerful prognostic markers in the overall cohort and in the separate races. In the receiver operating characteristic curve analysis, the areas under the curve at 1 and 2 years of follow-up were greater for the HFSS than for peak VO(2). In conclusion, HFSS and peak VO(2) can be used for transplant selection; however, in the era of modern therapy and across races and genders, the HFSS might perform better than the peak VO(2).

Mortality after hospitalization for heart failure in blacks compared to whites

Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. We identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality. We included 29 cohorts of hospitalized black and white patients with HF. The unadjusted mean mortality rate after HF hospitalization for black and white patients, respectively, was 6% and 9% for in-hospital, 6% and 10% for 30-day, 10% and 15% for 60- to 180-day, 28% and 34% for 1-year, and 41% and 47% for >1-year follow-up, respectively. The unadjusted combined odds ratios for mortality in black versus white patients ranged from 0.48 for in-hospital (95% confidence interval [CI] 0.45 to 0.51) to 0.77 after >1 year follow-up (95% CI 0.75 to 0.79). In meta-analyses using adjusted data, the combined odds ratio was 0.68 for short-term mortality (95% CI 0.63 to 0.74), and the combined hazard ratio was 0.84 for long-term mortality (95% CI 0.77 to 0.91). In conclusion, mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.

Medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with heart failure

BACKGROUND

Rehospitalization rates are higher in African American than Caucasian patients with heart failure (HF). The reasons for the disparity in outcomes between African Americans and Caucasians may relate to differences in medication adherence. To determine whether medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with HF.

METHODS AND RESULTS

Medication adherence was monitored longitudinally in 135 HF patients using the Medication Event Monitoring System. Events (emergency department visits for HF exacerbation, HF and cardiac rehospitalization, and all-cause mortality) were obtained by interview and hospital data base review. A series of regression models and survival analyses was conducted to determine whether medication adherence mediated the relationship between ethnicity and event-free survival. Event-free survival was significantly worse in African Americans than Caucasians. Ethnicity was a predictor of medication adherence (P=.011). African Americans were 2.57 times more likely to experience an event than Caucasians (P=.026). Ethnicity was not a predictor of event-free survival after entering medication adherence in the model (P=.06).

CONCLUSIONS

Medication adherence was a mediator of the relationship between ethnicity and event-free survival in this sample. Interventions designed to reduce barriers to medication adherence may decrease the disparity in outcomes.

Quality of care for heart failure among disabled Medicaid recipients with and without severe mental illness

OBJECTIVE

To examine the association between severe mental illness (SMI) and quality of care in heart failure.

METHODS

We conducted a cohort study between 2001 and 2004 of disabled Maryland Medicaid participants with heart failure. Quality measures and clinical outcomes were compared for individuals with and without SMI.

RESULTS

Of 1801 individuals identified with heart failure, 341 had comorbid SMI. SMI was not associated with differences in quality measures, including left ventricular assessment [adjusted relative risk (aRR) 0.99; 95% CI 0.91-1.07], utilization of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (aRR 1.04; 95% CI 0.92-1.17), or beta-blocker use (aRR 1.13; 95% CI 0.99-1.29). During the study period, 52.2% of individuals in the cohort filled a prescription for an ACE inhibitor or ARB and 45.5% filled a beta-blocker prescription. Individuals with and without SMI had similar rates of clinical outcomes, including hospitalizations, readmissions, and mortality. Both medication interventions were associated with improved mortality.

CONCLUSIONS

In this sample of disabled Medicaid recipients with heart failure, persons with SMI received similar quality of care as those without SMI. Both groups had low rates of beneficial medical treatments. Quality improvement programs should consider how best to target these vulnerable populations.

Relationship of hemoglobin A1C and mortality in heart failure patients with diabetes

OBJECTIVES

This study was designed to examine the relationship between glycosylated hemoglobin (HbA1C) and adverse outcomes in diabetic patients with established heart failure (HF).

BACKGROUND

Despite the common coexistence of diabetes and HF, previous studies examining the association between HbA1C and outcomes in this population have been limited and have reported discrepant results.

METHODS

We assessed the association between increasing quintiles (Q1 to Q5) of HbA1C and risk of death or risk of HF hospitalization by conducting a retrospective study in a national cohort of 5,815 veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers.

RESULTS

At 2 years of follow-up, death occurred in 25% of patients in Q1 (HbA1C < or =6.4%), 23% in Q2 (6.4% < HbA1c < or =7.1%), 17.7% in Q3 (7.1% < HbA1c < or =7.8%), 22.5% in Q4 (7.8% < HbA1c < or =9.0%), and 23.2% in Q5 (HbA1c >9.0%). After adjustment for potential confounders, the middle quintile (Q3) had reduced mortality when compared with the lowest quintile (risk-adjusted hazard ratio: 0.73, 95% confidence interval: 0.61 to 0.88, p = 0.001). Hospitalization rates for HF at 2 years increased with increasing quintiles of HbA1C (Q1: 13.3%, Q2: 13.1%, Q3: 15.5%, Q4: 16.4%, and Q5: 18.2%), but this association was not statistically significant when adjusted for potential confounders.

CONCLUSIONS

The association between mortality and HbA1C in diabetic patients with HF appears U-shaped, with the lowest risk of death in those patients with modest glucose control (7.1% < HbA1C < or =7.8%). Future prospective studies are necessary to define optimal treatment goals in these patients.

Prognostic characteristics of cardiopulmonary exercise testing in caucasian and African American patients with heart failure

Peak oxygen consumption (VO(2)) and ventilatory efficiency (minute ventilation/carbon dioxide output [VE/VCO(2)] slope) are prognostically important in heart failure (HF). The purpose of the present study was to compare the prognostic characteristics of these variables between Caucasian and African American patients. A total of 662 HF patients (455 Caucasian/207 African American) underwent cardiopulmonary exercise testing and were tracked for major cardiac events. The VE/VCO(2) slope was the strongest prognostic marker (chi-square >or=18.9, P<.001), irrespective of race. While peak VO(2) was a significant univariate predictor in both Caucasian (chi-square 42.0, P<.001) and African American (5.2, P=.02) subgroups, it was only retained in the Caucasian multivariate regression. The lack of predictive value of peak VO(2) in the African American subgroup was due to its lack of prognostic significance in female patients. While the VE/VCO(2) slope was the most robust prognostic marker in both Caucasian and African American patients, the predictive ability of peak VO(2) seems to be influenced by race and sex.

Differences in the incidence of congestive heart failure by ethnicity: the multi-ethnic study of atherosclerosis

BACKGROUND

The relationship between incident congestive heart failure (CHF) and ethnicity as well as racial/ethnic differences in the mechanisms leading to CHF have not been demonstrated in a multiracial, population-based study. Our objective was to evaluate the relationship between race/ethnicity and incident CHF.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) is a cohort study of 6814 participants of 4 ethnicities: white (38.5%), African American (27.8%), Hispanic (21.9%), and Chinese American (11.8%). Participants with a history of cardiovascular disease at baseline were excluded. Cox proportional hazards models were used for data analysis.

RESULTS

During a median follow-up of 4.0 years, 79 participants developed CHF (incidence rate: 3.1 per 1000 person-years). African Americans had the highest incidence rate of CHF, followed by Hispanic, white, and Chinese American participants (incidence rates: 4.6, 3.5, 2.4, and 1.0 per 1000 person-years, respectively). Although risk of developing CHF was higher among African American compared with white participants (hazard ratio, 1.8; 95% confidence interval, 1.1-3.1), adding hypertension and/or diabetes mellitus to models including ethnicity eliminated statistical ethnic differences in incident CHF. Moreover, African Americans had the highest proportion of incident CHF not preceded by clinical myocardial infarction (75%) compared with other ethnic groups (P = .06).

CONCLUSIONS

The higher risk of incident CHF among African Americans was related to differences in the prevalence of hypertension and diabetes mellitus as well as socioeconomic status. The mechanisms of CHF also differed by ethnicity; interim myocardial infarction had the least influence among African Americans, and left ventricular mass increase had the greatest effect among Hispanic and white participants.

Endothelial dysfunction in African-Americans

The journey of atherosclerosis begins with endothelial dysfunction and culminates into its most fearful destination producing ischemia, myocardial infarction and death. The excess cardiovascular disease morbidity and mortality in African-Americans is one of the major public health problems. In this review, we discuss vascular endothelial dysfunction as a key element for excess cardiovascular disease burden in this target population. It can be logical window of future atherosclerotic outcomes, and further efforts should be made to detect it at the earliest in African American individuals even if they are appearing healthy as the therapeutic interventions if instituted early, might prevent the subsequent cardiac events.

Evaluation of heart failure management in a Military Hospital

PURPOSE

Evaluate heart failure management in a Military Hospital in 2005.

METHODS

Retrospective audit of 46 case records of patients hospitalised with heart failure within the framework of an accreditation procedure.

RESULTS

The left ventricular ejection fraction was evaluated in 85% of cases during the reference hospital stay. Systolic heart failure was detected in 63% of cases. At least one NT-proBNP assay was performed for each patient. A global assessment was systematically performed, except for the mini mental state examination in patients aged over 75 years who represented 80% of patients. Initial therapeutic education was provided for 50% of systolic heart failure patients. Prescription rates in systolic heart failure were 76% for angiotensin-converting enzyme inhibitors, 7% for angiotensin receptor antagonists; 84% for at least one medicinal product in the above 2 classes; 68% for beta-blockers and 32% for spironolactone. A hospital discharge report was available for 93% of the patients. Elective re-admissions to hospital for uptitration of treatment concerned 10% of systolic heart failure patients. Emergency hospital re-admissions after a cardiovascular event (usually decompensation), concerned 35% of patients, after an average duration of one year of follow-up. These latter re-admissions, often repeated, led to 4% of additional hospital deaths. The initial hospital mortality rate was 13%.

CONCLUSION

Therapeutic patient education is under development. Medication may still be optimised, both qualitatively and quantitatively. Surveillance is planned with a yearly audit.

Race and the natural history of chronic heart failure: a propensity-matched study

BACKGROUND

Racial differences in the epidemiology and outcomes of heart failure are well known. However, the association of race with the natural history of heart failure has not been previously studied in a propensity-matched population of chronic heart failure in which all measured baseline patient characteristics are well-balanced between the races.

METHODS AND RESULTS

Of the 7788 patients with chronic systolic and diastolic heart failure in the Digitalis Investigation Group trial, 1128 were nonwhites. Propensity scores for being nonwhite were calculated for each patient and were used to match 1018 pairs of white and nonwhite patients. Matched Cox regression analyses were used to estimate associations of race with outcomes during 38 months of median follow-up. All-cause mortality occurred in 34% (rate, 1180/10000 person-years) of whites and 33% (rate, 1130/10000 person-years) of nonwhite patients (hazard ratio when nonwhite patients were compared with whites, 0.95, 95% confidence interval, 0.80-1.14; P = .593). All-cause hospitalization occurred in 63% (rate, 3616/10000 person-years) of whites and 65% (rate, 3877/10000 person-years) of nonwhite patients (hazard ratio, 1.03, 95% confidence interval, 0.90-1.18; P = .701). Respective hazard ratios (95% confidence intervals) for other outcomes were: 0.95 (0.75-1.12) for cardiovascular mortality, 0.82 (0.60-1.11) for heart failure mortality, 1.05 (0.91-1.22) for cardiovascular hospitalization, and 1.17 (0.98-1.39) for heart failure hospitalization.

CONCLUSIONS

In a propensity-matched population of heart failure patients where whites and nonwhites were balanced in all measured baseline characteristics, there were no racial differences in major natural history end points.

Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients

OBJECTIVES

The purpose of this study was to determine whether pay-for-performance (PFP) increases existing racial care disparities.

BACKGROUND

Medicare's PFP program provides financial rewards to hospitals whose care performance ranks in the highest quintile relative to peers and reduces funding to hospitals that rank in the lowest quintile. Pay-for-performance is designed to improve care but may disproportionately penalize hospitals caring for large minority populations.

METHODS

Using Medicare data, 3449 US hospitals were ranked by performance on PFP process measures for acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and heart failure (HF). These rankings were compared with the percentage of African American (AA) patients in a center. We determined the eligibility for financial bonus (highest quintile ranking) or penalty (lowest quintile) among centers treating large AA populations (> or = 20%) versus not after adjusting for hospital facility (catheterization, percutaneous coronary intervention, surgery), academic status, number of hospital beds, location, patient volume, and region.

RESULTS

The percentage of AA patients treated by a center was inversely associated with performance for AMI and CAP (P < .01) but not HF (P = .06). Relative to hospitals with < 20% AA, those with > or = 20% AA were less likely eligible for financial bonuses and more likely to face penalties: for AMI, adjusted odds ratio (OR) 0.7 (95% CI 0.5-1.0) and 1.8 (1.4-2.4), respectively; for CAP, OR 0.5 (95% CI 0.3-0.6) and 2.3 (1.8-2.9), respectively; for HF, OR 1.0 (95% CI 0.7-1.2) and 1.2 (0.9-1.5), respectively.

CONCLUSIONS

Hospitals with large minority populations may be at financial risk under PFP. Thus, PFP may worsen existing racial care disparities.

The Impact of Thiazolidinedione Use on Outcomes in Ambulatory Patients With Diabetes Mellitus and Heart Failure

OBJECTIVES

This study sought to examine the relationship between thiazolidinedione (TZD) use and outcomes in ambulatory patients with diabetes and heart failure (HF).

BACKGROUND

Thiazolidinediones have been relatively contraindicated in diabetic patients with HF.

METHODS

We conducted a retrospective study of a national cohort of veterans with HF and diabetes treated in ambulatory clinics at Veterans Affairs medical centers. Patients were classified into those using TZDs and those not using insulin-sensitizing medication based on prescriptions filled 90 days before or 30 days after the index outpatient visit. The outcomes were time to hospitalization for HF and time to death.

RESULTS

Of 7,147 ambulatory HF patients receiving diabetic therapy, 818 (11.4%) were receiving a TZD and 4,700 (65.8%) were not receiving insulin sensitizers. Over 2 years of follow-up, 134 (16.4%) patients receiving TZDs and 741 (15.8%) patients not receiving insulin-sensitizing medications required HF hospitalization (adjusted hazard ratio 1.00, 95% confidence interval 0.81 to 1.24, p = 0.97). A total of 168 (20.5%) patients receiving TZDs and 1,192 (25.4%) patients not receiving insulin-sensitizing medications died (adjusted hazard ratio 0.98, 95% confidence interval 0.81 to 1.17, p = 0.80).

CONCLUSIONS

In ambulatory patients with established HF and diabetes, the use of TZDs was not associated with an increased risk of HF hospitalization or total mortality when compared with those not receiving insulin-sensitizing medications.

Race-related differences in heart failure therapies: simply black and white or shades of grey?

The magnitude of burden imposed by heart failure on society has necessitated the evolution of innovative strategies to identify specific avenues of treatment and the populations at highest risk. Multiple studies have demonstrated a higher burden of cardiovascular disease in black Americans. It has also been shown that the clinical characteristics of heart failure, therapeutic targets, and response to various treatment modalities, are different in blacks as compared with whites. This article explores the unique race-related differences in heart failure with particular emphasis on the currently recommended therapeutic agents in heart failure.