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Faloye AO, Houston BT, Milam AJ. Racial and Ethnic Disparities in Cardiovascular Care. J Cardiothorac Vasc Anesth 2024; 38:1623-1626. [PMID: 38876812 DOI: 10.1053/j.jvca.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024]
Affiliation(s)
| | - Bobby T Houston
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Adam J Milam
- Department of Anesthesiology and Perioperative Medicine; Mayo Clinic; Phoenix, AZ
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Li R, Luo Q, Huddleston SJ. African Americans have worse outcomes after transcatheter and surgical aortic valve replacement: A national inpatient sample analysis from 2015 to 2020. J Cardiol 2024; 84:105-112. [PMID: 38373538 DOI: 10.1016/j.jjcc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are controversial among African Americans (AA). This study investigated racial disparities comparing AA and Caucasians undergoing aortic valve replacement. METHODS Patients who underwent SAVR and TAVR for aortic stenosis were identified in National Inpatient Sample from Q4 2015-2020. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared between AA and Caucasians using multivariable analysis, adjusting for sex, age, socioeconomic status, comorbidity, and hospital characteristics. RESULTS In TAVR, 51,394 (84.41 %) were Caucasians and 2433 (4.00 %) were AA. In SAVR, there were 50,080 (78.52 %) Caucasians and 3565 (5.59 %) AA. Compared to Caucasians, AA underwent TAVR had a higher risk of complications such as major adverse cardiovascular events (MACE) [adjusted odds ratio (aOR) = 1.335, p = 0.02)], respiratory complications (aOR = 1.363, p = 0.01), acute kidney injury (AKI) (aOR = 1.468, p < 0.01), pulmonary embolism (aOR = 4.65, p = 0.05), hemorrhage/hematoma (aOR = 1.202, p < 0.01), or superficial wound complication (aOR = 1.414, p = 0.04). AA who underwent SAVR had higher risks of morality (aOR = 1.184, p < 0.05) and surgical complications including MACE (aOR = 1.263, p < 0.01), pericardial complications (aOR = 1.563, p < 0.01), cardiogenic shock (aOR = 1.578, p < 0.01), respiratory complications (aOR = 1.261, p < 0.01), AKI (aOR = 1.642, p < 0.01), venous thromboembolism (aOR = 1.613, p < 0.01), hemorrhage/hematoma (aOR = 1.129, p < 0.01), infection (aOR = 1.234, p < 0.01), superficial wound complications (aOR = 1.756, p < 0.01), vascular complications (aOR = 1.592, p < 0.01), and diaphragmatic paralysis (aOR = 2.181, p = 0.02). In both TAVR and SAVR, AA had longer waiting times from admission to operation (p < 0.01), longer hospital stays (p < 0.01), and higher hospital charges (p < 0.01). CONCLUSION AA were underrepresented, especially in TAVR. AA experienced higher in-hospital mortality post-SAVR, but not after TAVR. Furthermore, AA had more complications for both TAVR and SAVR. These findings underscore the pronounced disparities among AA in aortic valve replacement.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Qianyun Luo
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stephen J Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Alahdab F, Ahmed AI, Nayfeh M, Han Y, Abdelkarim O, Alfawara MS, Little SH, Reardon MJ, Faza NN, Goel SS, Alkhouli M, Zoghbi W, Al-Mallah MH. Myocardial Blood Flow Reserve, Microvascular Coronary Health, and Myocardial Remodeling in Patients With Aortic Stenosis. J Am Heart Assoc 2024; 13:e033447. [PMID: 38780160 DOI: 10.1161/jaha.123.033447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/18/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Coronary microvascular function and hemodynamics may play a role in coronary circulation and myocardial remodeling in patients with aortic stenosis (AS). We aimed to evaluate the relationship between myocardial blood flow and myocardial function in patients with AS, no AS, and aortic valve sclerosis. METHODS AND RESULTS We included consecutive patients who had resting transthoracic echocardiography and clinically indicated positron emission tomography myocardial perfusion imaging to capture their left ventricular ejection fraction, global longitudinal strain (GLS), and myocardial flow reserve (MFR). The primary outcome was major adverse cardiovascular event (all-cause mortality, myocardial infarction, or late revascularization). There were 2778 patients (208 with aortic sclerosis, 39 with prosthetic aortic valve, 2406 with no AS, and 54, 49, and 22 with mild, moderate, and severe AS, respectively). Increasing AS severity was associated with impaired MFR (P<0.001) and GLS (P<0.001), even when perfusion was normal. Statistically significant associations were noted between MFR and GLS, MFR and left ventricular ejection fraction, and MFR and left ventricular ejection fraction reserve. After a median follow-up of 349 (interquartile range, 116-662) days, 4 (7.4%), 5 (10.2%), and 6 (27.3%) patients experienced a major adverse cardiovascular event in the mild, moderate, and severe AS groups, respectively. In a matched-control analysis, patients with mild-to-moderate AS had higher rates of impaired MFR (52.9% versus 39.9%; P=0.048) and major adverse cardiovascular event (11.8% versus 3.0%; P=0.002). CONCLUSIONS Despite lack of ischemia, as severity of AS increased, MFR decreased and GLS worsened, reflecting worse coronary microvascular health and myocardial remodeling. Positron emission tomography-derived MFR showed a significant independent correlation with left ventricular ejection fraction and GLS. Patients with prosthetic aortic valve showed a high prevalence of impaired MFR.
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Affiliation(s)
- Fares Alahdab
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Ahmed I Ahmed
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Malek Nayfeh
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Yushui Han
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Ola Abdelkarim
- Department of Cardiology, Faculty of Medicine Alexandria University Alexandria Egypt
| | | | | | | | - Nadeen N Faza
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Sachin S Goel
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | | | - William Zoghbi
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
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Shih E, Squiers JJ, Banwait JK, Harrington KB, Ryan WH, DiMaio JM, Schaffer JM. Race, neighborhood disadvantage, and survival of Medicare beneficiaries after aortic valve replacement and concomitant coronary artery bypass grafting. J Thorac Cardiovasc Surg 2024; 167:2076-2090.e19. [PMID: 36894351 DOI: 10.1016/j.jtcvs.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Race, neighborhood disadvantage, and the interaction between these 2 social determinants of health remain poorly understood with regards to survival after aortic valve replacement with concomitant coronary artery bypass grafting (AVR+CABG). METHODS Weighted Kaplan-Meier survival analyses and Cox proportional hazards modeling were used to evaluate the association between race, neighborhood disadvantage, and long-term survival in 205,408 Medicare beneficiaries undergoing AVR+CABG from 1999 to 2015. Neighborhood disadvantage was measured using the Area Deprivation Index, a broadly validated ranking of socioeconomic contextual disadvantage. RESULTS Self-identified race was 93.9% White and 3.2% Black. Residents of the most disadvantaged quintile of neighborhoods included 12.6% of all White beneficiaries and 40.0% of all Black beneficiaries. Black beneficiaries and residents of the most disadvantaged quintile of neighborhoods had more comorbidities compared with White beneficiaries and residents of the least disadvantaged quintile of neighborhoods, respectively. Increasing neighborhood disadvantage linearly increased the hazard for mortality for Medicare beneficiaries of White but not Black race. Residents of the most and least disadvantaged neighborhood quintiles had weighted median overall survival of 93.0 and 82.1 months, respectively, a significant difference (P < .001 by Cox test for equality of survival curves). Black and White beneficiaries had weighted median overall survival of 93.4 and 90.6 months, respectively, a nonsignificant difference (P = .29 by Cox test for equality of survival curves). A statistically significant interaction between race and neighborhood disadvantage was noted (likelihood ratio test P = .0215) and had implications on whether Black race was associated with survival. CONCLUSIONS Increasing neighborhood disadvantage was linearly associated with worse survival after combined AVR+CABG in White but not Black Medicare beneficiaries; race, however, was not independently associated with postoperative survival.
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Affiliation(s)
- Emily Shih
- Department of General Surgery, Baylor University Medical Center, Dallas, Tex; Baylor Scott and White Research Institute, Dallas, Tex.
| | - John J Squiers
- Department of General Surgery, Baylor University Medical Center, Dallas, Tex; Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | | | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - William H Ryan
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - J Michael DiMaio
- Baylor Scott and White Research Institute, Dallas, Tex; Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - Justin M Schaffer
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
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Li R, Choi BG. Native Americans have comparable transcatheter aortic valve replacement outcomes but higher stroke and venous thromboembolism after surgical aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:11-17. [PMID: 38052718 DOI: 10.1016/j.carrev.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Racial disparities in aortic valve replacement outcomes have been established. However, the current literature lacks comprehensive studies that examine the outcomes for Native Americans, probably due to their limited population size. This study aimed to investigate whether disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) also exist for outcomes among Native Americans. METHODS Patients who underwent SAVR and TAVR were identified in National Inpatient Sample from the last quarter of 2015 to 2020. A 1:5 propensity score matching was conducted between Native Americans and Caucasians. In-hospital perioperative outcomes, length of stay, wait from admission to operation, and total hospital charge, were compared. RESULTS In TAVR, 51,394 (84.41 %) were Caucasians and 171 (0.28 %) were Native Americans. In SAVR, there were 50,080 (78.52 %) Caucasians and 279 (0.44 %) Native Americans. After propensity matching, no significant difference was found in post-TAVR outcomes between Native Americans and Caucasians. However, Native Americans have a higher risk of neurological complications (2.88 % vs 0.79 %, p < 0.01) with stroke being the primary contributor (2.52 % vs 0.5 %, p < 0.01), as well as a higher incidence of venous thromboembolism (1.8 % vs 0.57 %, p < 0.05) after SAVR. CONCLUSIONS This study is the first to examine aortic valve replacement outcomes in Native Americans. Native Americans were found to be more likely to undergo SAVR than TAVR. Moreover, Native Americans were found to have five times higher stroke and three times higher VTE after SAVR. These disparities faced by Native Americans underscore the need for increased attention and targeted actions to guarantee health equity.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
| | - Brian G Choi
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
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Chen Y, Xiao Y, Huang R, Jiang F, Zhou J, Su C, Yang T. Association between hospital racial composition and aortic valve replacement outcomes: A national inpatients sample database analysis. Catheter Cardiovasc Interv 2024; 103:637-649. [PMID: 38353494 DOI: 10.1002/ccd.30970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/13/2024] [Accepted: 01/31/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Racial and ethnic disparities exist in the outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). However, it is unclear whether hospital racial composition contributes to these racial disparities. METHODS We analyzed the National Inpatient Sample (NIS) database from 2015 to 2019 to identify patients with aortic stenosis (AS) who received SAVR and TAVI. The Racial/Ethnic Diversity Index (RDI) was used to assess hospital racial composition as the proportion of nonwhite patients to total hospital admissions. Hospitals were categorized into RDI quintiles. Textbook outcome (TO) was defined as no in-hospital mortality, no postoperative complications and no prolonged length of stay (LOS). Multivariable mixed generalized linear models were conducted to assess the association between RDI and post-SAVR and post-TAVI outcomes. Moreover, quantile regression was used to assess the additional cost and length of stay associated with the RDI quintile. RESULTS The study included 82,502 SAVR or TAVI performed across 3285 hospitals, with 47.4% isolated SAVR and 52.5% isolated TAVI. After adjustment, quintiles 4 and 5 demonstrated significantly lower odds of TO than the lowest RDI quintile in both the SAVR cohort (quintile 4, 0.79 [95% CI, 0.73-0.85]; quintile 5, 0.79 [95% CI, 0.73-0.86]) and TAVI cohort (quintile 4, 0.88 [95% CI, 0.82-0.95]; quintile 5, 0.80 [95% CI, 0.74-0.86]). Despite non-observable differences in in-hospital mortality across all RDI quintiles, the rate of AKI and blood transfusion increased with increasing RDI for both cohorts. Further, Higher RDI quintiles were associated with increased costs and longer LOS. From 2015 to 2019, post-TAVI outcomes improved across all RDI quintiles. CONCLUSIONS Hospitals with a higher RDI experienced lower TO achievements, increased AKI, and blood transfusion, along with extended LOS and higher costs. Importantly, post-TAVI outcomes improved from 2015 to 2019 across all RDI groups.
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Affiliation(s)
- Yanfei Chen
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Yue Xiao
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Ruijian Huang
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Feng Jiang
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Jifang Zhou
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing Medical University, Nanjing, China
| | - Tianchi Yang
- Immunization Center, Ningbo Municipal Centre for Disease Control and Prevention, Ningbo, China
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Li R, Luo Q, Yanavitski M, Huddleston SJ. Disparity among Asian Americans in transcatheter and surgical aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 59:84-90. [PMID: 37673721 DOI: 10.1016/j.carrev.2023.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) outcomes have been established, but research has predominantly focused on African Americans and Hispanics, leaving a gap in Asian Americans. This study aimed to investigate disparities in aortic valve replacement outcomes among Asian Americans. METHODS Patients who underwent SAVR and TAVR were identified in National Inpatient Sample from the last quarter of 2015-2020. A 1:2 propensity score matching was applied to Asian Americans and Caucasians. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared. RESULTS In TAVR, 51,394 (84.41 %) were Caucasians and 795 (1.31 %) were Asian Americans. In SAVR, there were 50,080 (78.52 %) Caucasians and 1233 (1.93 %) Asian Americans. No significant difference was found in post-TAVR complications. However, Asian Americans experienced longer waiting time until operation (p = 0.03) and higher costs (p < 0.01) in TAVR. In SAVR, Asian Americans had higher risks of in-hospital mortality (3.91 % vs 2.39 %, p = 0.01), cardiogenic shock (8.71 % vs 6.74 %, p = 0.03), respiratory complications (14.08 % vs 11.2 %, p = 0.01), mechanical ventilation (13.83 % vs 9.09 %, p < 0.01), acute kidney injury (25.47 % vs 20.13 %, p < 0.01), and hemorrhage/hematoma (72.01 % vs 62.95 %, p < 0.01). Additionally, Asian Americans underwent SAVR had longer lengths of stay (p < 0.01) and higher costs (p < 0.01). CONCLUSIONS Asian Americans were underrepresented in aortic valve replacement. Asian Americans, while having similar post-TAVR outcomes to Caucasians, faced greater risks of post-SAVR mortality and surgical complications. These disparities among Asian Americans call for targeted actions to ensure equitable health outcomes.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America.
| | - Qianyun Luo
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America
| | - Marat Yanavitski
- M Health University of Minnesota Physicians, Cardiology East Division, Minneapolis, MN, United States of America
| | - Stephen J Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America
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Whelton SP, Jha K, Dardari Z, Razavi AC, Boakye E, Dzaye O, Verghese D, Shah S, Budoff MJ, Matsushita K, Carr JJ, Vasan RS, Blumenthal RS, Anchouche K, Thanassoulis G, Guo X, Rotter JI, McClelland RL, Post WS, Blaha MJ. Prevalence of Aortic Valve Calcium and the Long-Term Risk of Incident Severe Aortic Stenosis. JACC Cardiovasc Imaging 2024; 17:31-42. [PMID: 37178073 PMCID: PMC10902718 DOI: 10.1016/j.jcmg.2023.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Aortic valve calcification (AVC) is a principal mechanism underlying aortic stenosis (AS). OBJECTIVES This study sought to determine the prevalence of AVC and its association with the long-term risk for severe AS. METHODS Noncontrast cardiac computed tomography was performed among 6,814 participants free of known cardiovascular disease at MESA (Multi-Ethnic Study of Atherosclerosis) visit 1. AVC was quantified using the Agatston method, and normative age-, sex-, and race/ethnicity-specific AVC percentiles were derived. The adjudication of severe AS was performed via chart review of all hospital visits and supplemented with visit 6 echocardiographic data. The association between AVC and long-term incident severe AS was evaluated using multivariable Cox HRs. RESULTS AVC was present in 913 participants (13.4%). The probability of AVC >0 and AVC scores increased with age and were generally highest among men and White participants. In general, the probability of AVC >0 among women was equivalent to men of the same race/ethnicity who were approximately 10 years younger. Incident adjudicated severe AS occurred in 84 participants over a median follow-up of 16.7 years. Higher AVC scores were exponentially associated with the absolute risk and relative risk of severe AS with adjusted HRs of 12.9 (95% CI: 5.6-29.7), 76.4 (95% CI: 34.3-170.2), and 380.9 (95% CI: 169.7-855.0) for AVC groups 1 to 99, 100 to 299, and ≥300 compared with AVC = 0. CONCLUSIONS The probability of AVC >0 varied significantly by age, sex, and race/ethnicity. The risk of severe AS was exponentially higher with higher AVC scores, whereas AVC = 0 was associated with an extremely low long-term risk of severe AS. The measurement of AVC provides clinically relevant information to assess an individual's long-term risk for severe AS.
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Affiliation(s)
- Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Kunal Jha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Zeina Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Dhiran Verghese
- Department of Medicine, Harbor University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Sanjiv Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J Budoff
- Department of Medicine, Harbor University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J Jeffery Carr
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ramachandran S Vasan
- University of Texas School of Public Health San Antonio, San Antonio, Texas, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Khalil Anchouche
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Xiuqing Guo
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor University of California, Los Angeles Medical Center, Torrance, California, USA
| | - Jerome I Rotter
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor University of California, Los Angeles Medical Center, Torrance, California, USA
| | - Robyn L McClelland
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Wendy S Post
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Kulkarni A, Arafat M, Hou L, Liang S, Kassotis J. Racial Disparity Among Patients Undergoing Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in the United States. Angiology 2023; 74:812-821. [PMID: 36426842 DOI: 10.1177/00033197221137025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, racial disparities in the utilization of TAVR persist. This meta-analysis attempts to determine whether the prevalence of adverse outcomes (procedure-related complications) represent barriers to the use of TAVR among African Americans (AA). The TAVR cohort consisted of 89.6% Caucasian (C) and 4.7% AA, while the SAVR cohort included 86.9% C and 6.4% AA. The utilization rate (UR) of TAVR was 1.48 and .35 among C and AA, respectively, while the UR of SAVR was 1.44 and .48 among C and AA, respectively. Following TAVR, for AA the odds ratio (OR) was greater for stroke (OR = 1.22, P = .02) and transient ischemic attack (TIA) (OR = 1.57, P < .001) and lower for undergoing the insertion of a permanent pacemaker (OR = .81, P < .001). While there was a significant difference between C and AA in TAVR and SAVR utilization, outcomes between groups following TAVR are comparable; therefore, adverse outcomes do not appear to be a barrier to the use of TAVR among eligible AA.
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Affiliation(s)
- Abha Kulkarni
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Mohammod Arafat
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Linle Hou
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shiochee Liang
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John Kassotis
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Rice CT, Barnett S, O'Connell SP, Akowuah E, Appleby CE, Chambers JB, Shah BN, Blackman DJ. Impact of gender, ethnicity and social deprivation on access to surgical or transcatheter aortic valve replacement in aortic stenosis: a retrospective database study in England. Open Heart 2023; 10:e002373. [PMID: 37788920 PMCID: PMC10565153 DOI: 10.1136/openhrt-2023-002373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/07/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVE To assess gender, ethnicity, and deprivation-based differences in provision of aortic valve replacement (AVR) in England for adults with aortic stenosis (AS). METHODS We retrospectively identified adults with AS from the English Hospital Episode Statistics (HES) between April 2016 and March 2019 and those who subsequently had an AVR. We separately used HES-linked Clinical Practice Research Datalink (CPRD) to identify people with AVR and evaluate the timeliness of their procedure (CPRD-AVR cohort). ORs for AVR in people with an AS diagnosis were estimated using multivariable logistic regression adjusted for age, region and comorbidity. AVR was considered timely if performed electively and without evidence of cardiac decompensation before AVR. RESULTS 183 591 adults with AS were identified in HES; of these, 31 436 underwent AVR. The CPRD-AVR cohort comprised 10 069 adults. Women had lower odds of receiving AVR compared with men (OR 0.65; 95% CI 0.63 to 0.66); as did people of black (OR 0.70; 95% CI 0.60 to 0.82) or South Asian (OR 0.75; 95% CI 0.69 to 0.82) compared with people of white ethnicities. People in the most deprived areas were less likely to receive AVR than the least deprived areas (OR 0.8; 95% CI 0.75 to 0.86). Timely AVR occurred in 65% of those of white ethnicities compared with 55% of both those of black and South Asian ethnicities. 77% of the least deprived had a timely procedure compared with 58% of the most deprived; there was no gender difference. CONCLUSIONS In this large, national dataset, female gender, black or South Asian ethnicities and high deprivation were associated with significantly reduced odds of receiving AVR in England. A lower proportion of people of minority ethnicities or high deprivation had a timely procedure. Public health initiatives may be required to increase clinician and public awareness of unconscious biases towards minority and vulnerable populations to ensure timely AVR for everyone.
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Affiliation(s)
| | - Sophie Barnett
- Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | | | - Enoch Akowuah
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Clare E Appleby
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Benoy N Shah
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Daniel J Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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11
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Hassan SMA, Ghunaim A, Verma R, Sicilia A, Yanagawa B. Racial and ethnic differences in aortic stenosis: the tip of the iceberg. Curr Opin Cardiol 2023; 38:103-107. [PMID: 36718619 DOI: 10.1097/hco.0000000000001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW There is a lack of data on the epidemiology and management of severe aortic stenosis (AS) in diverse populations. We summarize the contemporary literature on the racial and ethnic differences in AS prevalence, treatment and outcomes and discuss possible explanations for these disparities to inform future research and improve the delivery of care to under-represented patient groups. RECENT FINDINGS African American (AA) patients have significantly less prevalence of severe AS than White patients whereas paradoxically having higher traditional risk factors for severe AS. Non-White patients have less referral for aortic valve replacement (AVR) after adjusting for clinical and echocardiographic parameters. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are both underutilized in non-White patients. Differences in race and ethnicity have not shown to result in worse in-hospital and long-term survival outcomes after either SAVR or TAVR. SUMMARY Much research is warranted to explore the epidemiology, true prevalence and treatment outcomes of severe AS in diverse populations. Greater inclusion of non-White ethnic groups in the primary analysis of prospective trials is needed. Lastly, further research is warranted to explore the complex causes of racial and ethnic disparities in utilization of surgical and transcatheter interventions.
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Affiliation(s)
- Syed M Ali Hassan
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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12
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Affiliation(s)
- Puja B. Parikh
- Division of Cardiovascular Medicine, Department of MedicineStony Brook University Renaissance School of MedicineStony BrookNY
| | - Smadar Kort
- Division of Cardiovascular Medicine, Department of MedicineStony Brook University Renaissance School of MedicineStony BrookNY
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13
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Crousillat DR, Amponsah DK, Camacho A, Kandanelly RR, Bapat D, Chen C, Selberg A, Shaqdan A, Tanguturi VK, Picard MH, Hung JW, Elmariah S. Racial and Ethnic Differences in the Clinical Diagnosis of Aortic Stenosis. J Am Heart Assoc 2022; 11:e025692. [PMID: 36533618 PMCID: PMC9798798 DOI: 10.1161/jaha.122.025692] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Racial and ethnic minority groups are underrepresented among patients undergoing aortic valve replacement in the United States. We evaluated the impact of race and ethnicity on the diagnosis of aortic stenosis (AS). Methods and Results In patients with transthoracic echocardiography (TTE)-confirmed AS, we assessed rates of AS diagnosis as defined by assignment of an International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) code for AS within a large multicenter electronic health record. Multivariable Cox proportional hazard and competing risk regression models were used to evaluate the 1-year rate of AS diagnosis by race and ethnicity. Among 14 800 patients with AS, the 1-year diagnosis rate for AS following TTE was 37.4%. Increasing AS severity was associated with an increased likelihood of receiving an AS diagnosis (moderate: hazard ratio [HR], 3.05 [95% CI, 2.86-3.25]; P<0.0001; severe: HR, 4.82 [95% CI, 4.41-5.28]; P<0.0001). Compared with non-Hispanic White, non-Hispanic Black (HR, 0.65 [95% CI, 0.54-0.77]; P<0.0001) and non-Hispanic Asian individuals (HR, 0.72 [95% CI, 0.57-0.90], P=0.004) were less likely to receive a diagnosis of AS. Additional factors associated with a decreased likelihood of receiving an AS diagnosis included a noncardiology TTE ordering provider (HR, 0.92 [95% CI, 0.86-0.97]; P=0.005) and TTE performed in the inpatient setting (HR, 0.72 [95% CI, 0.66-0.78]; P<0.0001). Conclusions Rates of receiving an ICD diagnostic code for AS following a diagnostic TTE are low and vary significantly by race and ethnicity and disease severity. Further studies are needed to determine if efforts to maximize the clinical recognition of TTE-confirmed AS may help to mitigate disparities in treatment.
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Affiliation(s)
- Daniela R. Crousillat
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA,Division of Cardiovascular SciencesUniversity of South FloridaTampaFL
| | - Daniel K. Amponsah
- Department of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Alexander Camacho
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Ritvik R. Kandanelly
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Devavrat Bapat
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Chen Chen
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Alexandra Selberg
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Ayman Shaqdan
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Varsha K. Tanguturi
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Michael H. Picard
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Judy W. Hung
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Sammy Elmariah
- Cardiology Division, Massachusetts General HospitalHarvard Medical SchoolBostonMA,Cardiology DivisionUniversity of California San FranciscoSan FranciscoCA
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14
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Cohen BD, Aminpour N, Wang H, Sellke FW, Al-Refaie WB, Ehsan A. Did ethno-racial disparities in access to transcatheter aortic valve replacement change over time? JTCVS OPEN 2022; 12:71-83. [PMID: 36590742 PMCID: PMC9801242 DOI: 10.1016/j.xjon.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/25/2022] [Accepted: 07/01/2022] [Indexed: 01/04/2023]
Abstract
Objective In this study we sought to evaluate whether disparate use of transcatheter aortic valve replacement (TAVR) among non-White patients has decreased over time, and if unequal access to TAVR is driven by unequal access to high-volume hospitals. Methods From 2013 to 2017, we used the State Inpatient Database across 8 states (Ariz, Colo, Fla, Md, NC, NM, Nev, Wash) to identify 51,232 Medicare beneficiaries who underwent TAVR versus surgical aortic valve replacement. Hospitals were categorized as low- (<50 per year), medium- (50-100 per year), or high-volume (>100 per year) according to total valve procedures (TAVR + surgical aortic valve replacement). Multivariable logistic regression models with interactions were performed to determine the effect of race, time, and hospital volume on the utilization of TAVR. Results Non-White patients were less likely to receive TAVR than White patients (odds ratio [OR], 0.77; 95% CI, 0.71-0.83). However, utilization of TAVR increased over time (OR, 1.73; 95% CI, 1.73-1.80) for the total population, with non-White patients' TAVR use growing faster than for White patients (OR, 1.06; 95% CI, 1.00-1.12), time × race interaction, P = .034. Further, an adjusted volume-stratified time trend analysis showed that utilization of TAVR at high volume hospitals increased faster for non-White patients versus White patients by 8.6% per year (OR, 1.09; 95% CI, 1.01-1.16) whereas use at low- and medium-volume hospitals did not contribute to any decreasing utilization gap. Conclusions This analysis shows initial low rates of TAVR utilization among non-White patients followed by accelerated use over time, relative to White patients. This narrowing gap was driven by increased TAVR utilization by non-White patients at high-volume hospitals.
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Affiliation(s)
- Brian D. Cohen
- Department of Surgery, MedStar Georgetown/Washington Hospital Center, Washington, DC
| | | | - Haijun Wang
- MedStar Health Research Institute, Hyattsville, Md
| | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI
| | - Waddah B. Al-Refaie
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC,Address for reprints: Waddah B. Al-Refaie, MD, FACS, MedStar Georgetown University Hospital, MedStar-Georgetown Surgical Outcomes Research Center, Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd NW, PHC Building, 4th Floor, Washington, DC 20007.
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI
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15
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Lamprea-Montealegre JA, Oyetunji S, Bagur R, Otto CM. Valvular Heart Disease in Relation to Race and Ethnicity: JACC Focus Seminar 4/9. J Am Coll Cardiol 2021; 78:2493-2504. [PMID: 34886971 DOI: 10.1016/j.jacc.2021.04.109] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/06/2021] [Indexed: 12/28/2022]
Abstract
Valvular heart disease (VHD) is a major global public health problem. Many regions of the world continue to grapple with the adverse consequences of untreated rheumatic heart disease, a condition that is largely preventable with timely access to diagnosis and treatment. In turn, middle- and high-income countries have experienced a rise in the prevalence of calcific aortic and mitral disease, owing in part to population aging. This public health problem is further compounded by high rates of infective endocarditis, which is associated with substantial morbidity and mortality. Yet, considerations of race and ethnicity have not taken center stage in VHD research. This is despite evidence of major health care disparities in socioeconomic and medical risk factors, access to diagnosis, and provision of appropriate treatment. In this paper, the authors review differences in the etiology, diagnosis, and treatment of VHD within the context of race, ethnicity, and health care disparities.
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Affiliation(s)
- Julio A Lamprea-Montealegre
- Division of Cardiology and Kidney Health Research Collaborative, University of California-San Francisco, San Francisco, California, USA
| | - Shakirat Oyetunji
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington, USA
| | - Rodrigo Bagur
- Division of Cardiology, Western University, London, Ontario, Canada
| | - Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA.
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16
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Lian Q, Wang J, Lian Y, Yang Q, Zhao M, Zhang Y. Impact of valvular heart disease on hip replacement: a retrospective nationwide inpatient sample database study. BMC Musculoskelet Disord 2021; 22:860. [PMID: 34627205 PMCID: PMC8501620 DOI: 10.1186/s12891-021-04738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To study the impact of valvular heart disease (VHD) on hip replacement, particularly the clinical impactions of aortic stenosis before total/partial hip arthroplasty. METHODS This was a retrospective cohort study. Data on patients who had undergone hip replacement from 2005 to 2014 were extracted from the NIS database. Independent t test and chi-square test were used to analyze the essential characteristics of patients. Multivariate regression was used to estimate the correlation among demographics, comorbidities, complications, hospitalization costs, and time. RESULTS VHD accounted for 5.56% and AS accounted for 0.03% of the patients before hip replacement surgeries. Patients with VHD before hip replacement are related to the following characteristics: female patients (odds ratio [OR] = 1.15 [1.12-1.18]), elective admission (OR = 0.78 [0.76-0.80]), Charlson Comorbidity Index ≥3 (OR = 1.06 [1.03-1.08]), large-volume hospitals (OR = 1.13 [1.1-1.2]), teaching hospitals (OR = 5 4.4 [2.9-6.7]), and hospital location in urban areas (OR = 1.22 [1.2-1.3]). In addition, VHD is a risk factor for mortality and some acute postoperative medical complications, such as acute cardiac event (OR = 2.96 [2.87-3.04]), acute pulmonary edema (OR = 1.13 [1.06-1.21]), acute cerebrovascular event (OR = 1.22 [1.16-1.74]), and acute renal failure (OR = 1.22 [1.17-1.27]). It also has an impact on DVT/PE (OR = 0.89 [0.8-0.99]). Patients with AS before hip replacement have basic demographic characteristics like those of hip replacement patients with valvular disease. Patients with AS are older than those without AS before surgery (OR = 3.28 [2.27-4.75) and are related to the following characteristics: female patients (OR = 1.92 [1.32-2.8]) and elective admission (OR = 0.51 [0.36-0.75]). The perioperative period is limited to acute postoperative complications, such as acute cardiac events (OR = 2.50 [1.76-3.53]) and acute hepatic failure (OR = 7.69 [1.8-32.89]). Both valvular diseases and AS are associated with a higher mortality rate and hospitalization cost. CONCLUSION VHD independently predicted mortality rate and surgical and medical complications after total/partial hip arthroplasty.
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Affiliation(s)
- Qiang Lian
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China
| | - Jian Wang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China
| | - Yun Lian
- First Affiliation Hospital of Nanchang University, Nanchang City, Jiangxi Province, China
| | - Qinfeng Yang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China
| | - Mingchen Zhao
- Goodwill Hessian Health Technology Co., Ltd., Beijing, 100007, China
| | - Yang Zhang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, 510515, Guangdong, China.
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17
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Govea N, Jotwani R, Bonaparte C, Komlan AG, White RS, Hoyler M. The economic cost of racial disparities in patients undergoing cardiac valve repair or replacement. J Comp Eff Res 2021; 10:1031-1034. [PMID: 34431362 DOI: 10.2217/cer-2021-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Nicolas Govea
- Department of Anesthesiology, New York-Presbyterian Weill Cornell Medical Center, NY 10065, USA
| | - Rohan Jotwani
- Department of Anesthesiology, New York-Presbyterian Weill Cornell Medical Center, NY 10065, USA
| | - Christina Bonaparte
- Department of Public Health, School of Public Health, Brown University, Providence, RI 02915, USA
| | | | - Robert S White
- Department of Anesthesiology, New York-Presbyterian Weill Cornell Medical Center, NY 10065, USA
| | - Marguerite Hoyler
- Department of Anesthesiology, New York-Presbyterian Weill Cornell Medical Center, NY 10065, USA
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18
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Czarny MJ, Hasan RK, Post WS, Chacko M, Schena S, Resar JR. Inequities in Aortic Stenosis and Aortic Valve Replacement Between Black/African-American, White, and Hispanic Residents of Maryland. J Am Heart Assoc 2021; 10:e017487. [PMID: 34261361 PMCID: PMC8483496 DOI: 10.1161/jaha.120.017487] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Racial and ethnic inequities exist in surgical aortic valve replacement for aortic stenosis (AS), and early studies have suggested similar inequities in transcatheter aortic valve replacement. Methods and Results We performed a retrospective analysis of the Maryland Health Services Cost Review Commission inpatient data set from 2016 to 2018. Black patients had half the incidence of any inpatient AS diagnosis compared with White patients (incidence rate ratio [IRR], 0.50; 95% CI, 0.48–0.52; P<0.001) and Hispanic patients had one fourth the incidence compared with White patients (IRR, 0.25; 95% CI, 0.22–0.29; P<0.001). Conversely, the incidence of any inpatient mitral regurgitation diagnosis did not differ between White and Black patients (IRR, 1.00; 95% CI, 0.97–1.03; P=0.97) but was significantly lower in Hispanic compared with White patients (IRR, 0.36; 95% CI, 0.33–0.40; P<0.001). After multivariable adjustment, Black race was associated with a lower incidence of surgical aortic valve replacement (IRR, 0.67; 95% CI, 0.55–0.82 P<0.001 relative to White race) and transcatheter aortic valve replacement (IRR, 0.77; 95% CI, 0.65–0.90; P=0.002) among those with any inpatient diagnosis of AS. Hispanic patients had a similar rate of surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients. Conclusions Hospitalization with any diagnosis of AS is less common in Black and Hispanic patients than in White patients. In hospitalized patients with AS, Black race is associated with a lower incidence of both surgical aortic valve replacement and transcatheter aortic valve replacement compared with White patients, whereas Hispanic patients have a similar incidence of both. The reasons for these inequities are likely multifactorial.
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Affiliation(s)
- Matthew J Czarny
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Rani K Hasan
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Wendy S Post
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Matthews Chacko
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
| | - Stefano Schena
- Division of Cardiothoracic Surgery School of Medicine Johns Hopkins University Baltimore MD
| | - Jon R Resar
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD
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19
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Erinne I, Sethi A, Johannesen J, Kassotis J. Racial disparities in the treatment of aortic stenosis: Has transcatheter aortic valve replacement bridged the gap? Catheter Cardiovasc Interv 2021; 98:148-156. [PMID: 33527675 DOI: 10.1002/ccd.29487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Racial disparities in outcomes and utilization of surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis (AS) is well known. While transcatheter aortic valve replacement (TAVR) has become more widespread, its impact on racial disparities remains unclear. OBJECTIVES Our goal was to assess the utilization of SAVR and TAVR and their clinical outcomes among various racial groups. METHODS The National Inpatient database (2009-2015) was used to study the racial distribution of admissions for SAVR and TAVR, and their impact on inpatient outcomes. Survey estimation commands were used to determine weighted national estimates. RESULTS There were 3,445,267; 294,108; and 52,913 inpatient visits for AS, SAVR, and TAVR, respectively. SAVR visits were 86% White, 3.8% Black, 5.5% Hispanic, 1.2% Asian/Pacific Islander (A/PI), 0.4% Native American (NA), and 2.9%; TAVR were 87.7% White, 3.7% Black, 3.8% Hispanic, 1.0% A/PI, 0.2% NA, and 3.5% Other while AS visits were 83.7% White, 6.7% Black, 5.3% Hispanic, 1.7% A/PI, 0.4% NA, and 2.2% Other. Racial minorities generally had more co-morbidities compared with Whites. After SAVR, Black patients had a higher unadjusted inpatient mortality than Whites, however, there was no difference after adjustment for other variables. A/PI were more likely to require a permanent pacemaker after SAVR. Need for blood transfusion was significantly higher among the minorities compared with Whites, except for NA, but there were no racial differences in stroke rates. There was no difference in inpatient mortality, pacemaker implantation, stroke, and bleeding after TAVR, but acute kidney injury occurred more often in Hispanics, A/PI, and "others" compared with Whites. CONCLUSIONS Racial disparities in the treatment of AS continues in the contemporary era; however it was found that TAVR resulted in comparable inpatient outcomes, despite higher comorbidities, and adverse socioeconomic factors in minorities.
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Affiliation(s)
- Ikenna Erinne
- Division of Cardiology, Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ankur Sethi
- Department of Cardiology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Justin Johannesen
- Division of Cardiology, Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - John Kassotis
- Division of Cardiology, Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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20
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Ullah W, Al-Khadra Y, Mir T, Darmoch F, Pacha HM, Sattar Y, Ijioma N, Mohamed MO, Kwok CS, Asfour AI, Kapadia S, Rizik D, Zehr K, Mamas MA, Alraies MC. Temporal trends in utilization and outcomes of transcatheter aortic valve replacement in different races: an analysis of the national inpatient sample. J Cardiovasc Med (Hagerstown) 2021; 22:586-593. [PMID: 34076606 DOI: 10.2459/jcm.0000000000001172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM We sought to determine the racial and ethnical disparities in the delivery of TAVR and to evaluate the in-hospital outcomes and utilization of TAVR stratified by patient ethnicity. METHOD Using a national inpatient sample database between 2011 and 2015, we identified all adult patients who had TAVR. Races were identified and white race was set as control. Multiple logistic regression analysis was performed for the primary outcome of in-hospital mortality. RESULTS Out of 58 174 patients who underwent TAVR, 50 809 (87.3%) were white, 2327 (4.0%) were black, 2311 (4.0%) were Hispanic, 640 (1.1%) Asian, 105 (0.2%) Native American and 1982 (3.4%) of other ethnicities. We found a statistically significant linear uptrend in the utilization of TAVR in patients of all races between the years 2011 and 2015. White, black, Hispanic and Native American patients had a downward linear trend for mortality during the studied years (P ≤ 0.005 for all). Black patients had lower in-hospital mortality [2.8 vs. 3.6%, odds ratio (OR) = 0.62; 95% confidence interval (CI) 0.44, 0.81 P < 0.001] compared with white patients, whereas Hispanic patients and Native Americans had higher in-hospital mortality compared with white patients (4.5% OR 1.26; 95% CI 1.01, 1.56 P = 0.041), (9.5% OR 4.44; 95% CI 2.25, 8.77 P < 0.001), respectively. CONCLUSION Overall, TAVR utilization is associated with lower mortality. There is a rising trend in utilization of TAVR in the black population with a significantly favorable mortality trend compared with the white population.
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Affiliation(s)
- Waqas Ullah
- Division of Cardiology, Abington Jefferson Health, Abington, Pennsylvania
| | - Yasser Al-Khadra
- Division of Cardiology, Cleveland Clinic, Internal Medicine, Cleveland, Ohio
| | - Tanveer Mir
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, Michigan
| | - Fahed Darmoch
- Division of Cardiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Homam M Pacha
- Division of Cardiology, University of Texas Health Science Center, Houston, Texas
| | - Yasar Sattar
- Division of Cardiology, Icahn School of Medicine at Mount Sinai Elmhurst Hospital New York, New York, New York
| | - Nketchi Ijioma
- Division of Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed O Mohamed
- Division of Cardiology, Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Chun S Kwok
- Division of Cardiology, Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Samir Kapadia
- Division of Cardiology, Abington Jefferson Health, Abington, Pennsylvania
| | - David Rizik
- Division of Cardiology, HonorHealth, Phoenix, Arizona, USA
| | - Kenton Zehr
- Division of Cardiology, Cleveland Clinic, Internal Medicine, Cleveland, Ohio
| | - Mamas A Mamas
- Division of Cardiology, Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - M Chadi Alraies
- Division of Cardiology, Cleveland Clinic, Internal Medicine, Cleveland, Ohio
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21
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Owens DS, Bartz TM, Buzkova P, Massera D, Biggs ML, Carlson SD, Psaty BM, Sotoodehnia N, Gottdiener JS, Kizer JR. Cumulative burden of clinically significant aortic stenosis in community-dwelling older adults. Heart 2021; 107:1493-1502. [PMID: 34083406 DOI: 10.1136/heartjnl-2021-319025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/03/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Current estimates of aortic stenosis (AS) frequency have mostly relied on cross-sectional echocardiographic or longitudinal administrative data, making understanding of AS burden incomplete. We performed case adjudications to evaluate the frequency of AS and assess differences by age, sex and race in an older cohort with long-term follow-up. METHODS We developed case-capture methods using study echocardiograms, procedure and diagnosis codes, heart failure events and deaths for targeted review of medical records in the Cardiovascular Health Study to identify moderate or severe AS and related procedures or hospitalisations. The primary outcome was clinically significant AS (severe AS or procedure). Assessment of incident AS burden was based on subdistribution survival methods, while associations with age, sex and race relied on cause-specific survival methods. RESULTS The cohort comprised 5795 participants (age 73±6, 42.2% male, 14.3% Black). Cumulative frequency of clinically significant AS at maximal 25-year follow-up was 3.69% (probable/definite) to 4.67% (possible/probable/definite), while the corresponding 20-year cumulative incidence was 2.88% to 3.71%. Of incident cases, about 85% had a hospitalisation for severe AS, but roughly half did not undergo valve intervention. The adjusted incidence of clinically significant AS was higher in men (HR 1.62 [95% CI 1.21 to 2.17]) and increased with age (HR 1.08 [95% CI 1.04 to 1.11]), but was lower in Blacks (HR 0.43 [95% CI 0.23 to 0.81]). CONCLUSIONS In this community-based study, we identified a higher burden of clinically significant AS than reported previously, with differences by age, sex and race. These findings have important implications for public health resource planning, although the lower burden in Blacks merits further study.
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Affiliation(s)
- David S Owens
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Traci M Bartz
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Petra Buzkova
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Daniele Massera
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York, USA
| | - Mary L Biggs
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Selma D Carlson
- Division of Cardiology, Department of Medicine, Minneapolis Veterans Affairs Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology and Health Services, University of Washington, Seattle, Washington, USA
| | - Nona Sotoodehnia
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA.,Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology and Health Services, University of Washington, Seattle, Washington, USA
| | - John S Gottdiener
- Division of Cardiology, Department of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jorge R Kizer
- Cardiology Section, San Francisco VA Health Care System, San Francisco, California, USA .,Departments of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Grines CL, Klein AJ, Bauser-Heaton H, Alkhouli M, Katukuri N, Aggarwal V, Altin SE, Batchelor WB, Blankenship JC, Fakorede F, Hawkins B, Hernandez GA, Ijioma N, Keeshan B, Li J, Ligon RA, Pineda A, Sandoval Y, Young MN. Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease. Catheter Cardiovasc Interv 2021; 98:277-294. [PMID: 33909339 DOI: 10.1002/ccd.29745] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.
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Affiliation(s)
- Cindy L Grines
- Cardiology, Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
| | - Andrew J Klein
- Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Holly Bauser-Heaton
- Pediatric Cardiology, Sibley Heart Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Neelima Katukuri
- Cardiology, Orlando VA Medical Center, University of Central Florida, Orlando, Florida, USA
| | - Varun Aggarwal
- Pediatric Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - S Elissa Altin
- Cardiovascular Disease, Yale University, New Haven, Connecticut, USA
| | - Wayne B Batchelor
- Interventional Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - James C Blankenship
- Internal Medicine, Cardiology Division, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Foluso Fakorede
- Interventional Cardiology, Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi, USA
| | - Beau Hawkins
- Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Gabriel A Hernandez
- Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Britton Keeshan
- Clinical Pediatrics, Yale New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Jun Li
- Cardiology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - R Allen Ligon
- Pediatric Cardiology, Joe DiMaggio Children's Hospital - Memorial Healthcare System, Hollywood, Florida, USA
| | - Andres Pineda
- Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Michael N Young
- Cardiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Alkhouli M, Alqahtani F, Ziada KM, Aljohani S, Holmes DR, Mathew V. Contemporary trends in the management of aortic stenosis in the USA. Eur Heart J 2021; 41:921-928. [PMID: 31408096 DOI: 10.1093/eurheartj/ehz568] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/31/2019] [Accepted: 07/25/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS To assess the contemporary trends in aortic stenosis (AS) interventions in the USA before and after the introduction of transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We utilized the National-Inpatient-Sample to assess temporal trends in the incidence, cost, and outcomes of AS interventions between 1 January 2003 and 31 December 2016. During the study's period, AS interventions increased from 96 to 137 per 100 000 individuals > 60 years old, P < 0.001. In-hospital expenditure on AS interventions increased from $2.28 billion in 2003 to $4.33 in 2016 P < 0.001. Among patients who underwent aortic valve replacement, the proportion of TAVI increased from 11.9% in 2012 to 43.2% in 2016 (P < 0.001). Males and Hispanics had lower proportions of TAVI compared with females and White patients. Adjusted in-hospital mortality of isolated SAVR decreased from 5.4% in 2003 to 3.3% in 2016 (P < 0.001), whereas adjusted in-hospital mortality of TAVI decreased from 4.7% in 2012 to 2.2% in 2016, P < 0.001. The incidence of new dialysis, permanent pacemaker implantation, and blood transfusion decreased after both TAVI and SAVR between 2012 and 2016. However, the rate of post-operative stroke did not significantly decrease. Length of stay and cost of hospitalization decreased after both SAVR and TAVI, although the later remained higher with TAVI. Rates of non-home discharge decreased over time after TAVI but remained stable after isolated SAVR. CONCLUSION This nationwide survey documents the increasing incidence of AS interventions, the rising cost of modern AS care, and the paradigm shift in aortic valve replacement practice in the USA.
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Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiology, Department of Medicine, West Virginia University, 1 Medical Drive, Morgantown, WV 26505, USA.,Department of Cardiology, Mayo Clinic School of Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Fahad Alqahtani
- Division of Cardiology, Department of Medicine, West Virginia University, 1 Medical Drive, Morgantown, WV 26505, USA
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, University of Kentucky, 326 C.T. Wethington Bldg, 900 S Limestone St, Lexington, KY 40536, USA
| | - Sami Aljohani
- Division of Cardiology, Department of Medicine, West Virginia University, 1 Medical Drive, Morgantown, WV 26505, USA
| | - David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, 200 First St. SW Rochester, MN 55905, USA
| | - Verghese Mathew
- Division of Cardiology, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL 60153, USA
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24
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Yankey GS, Jackson LR, Marts C, Chiswell K, Wu A, Ugowe F, Wilson J, Vemulapalli S, Samad Z, Thomas KL. African American-Caucasian American differences in aortic valve replacement in patients with severe aortic stenosis. Am Heart J 2021; 234:111-121. [PMID: 33453161 PMCID: PMC9899489 DOI: 10.1016/j.ahj.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among patients with severe aortic stenosis (AS), there are limited data on aortic valve replacement (AVR), reasons for nonreceipt and mortality by race. METHODS Utilizing the Duke Echocardiography Laboratory Database, we analyzed data from 110,711 patients who underwent echocardiography at Duke University Medical Center between 1999 and 2013. We identified 1,111 patients with severe AS who met ≥1 of 3 criteria for AVR: ejection fraction ≤50%, diagnosis of heart failure, or need for coronary artery bypass surgery. Logistic regression models were used to assess the association between race, AVR and 1-year mortality. χ2 testing was used to assess potential racial differences in reasons for AVR nonreceipt. RESULTS Among the 1,111 patients (143 AA and 968 CA) eligible for AVR, AA were more often women, had more diabetes, renal insufficiency, aortic regurgitation and left ventricular hypertrophy. CA were more often smokers, had more ischemic heart disease, hyperlipidemia and higher median income levels. There were no racial differences in surgical risk utilizing logistic euroSCORES. Relative to CA, AA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) yet similar 1-year mortality (aHR 0.81, 95% CI 0.57-1.17, P = .262). There were no significant differences in reasons for AVR nonreceipt. CONCLUSIONS We identified 143 African Americans (AA) and 968 Caucasian Americans(CA) with severe AS who met prespecified criteria for AVR.. AA relative to CA were more often women, had more diabetes, renal insufficiency, and left ventricular hypertrophy, however had less tobacco use, ischemic heart disease, hyperlipidemia and lower median income levels. Among patients with severe AS, AA relative to CA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) without significant differences in reasons for AVR nonreceipt and similar 1-year mortality.
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Affiliation(s)
| | - Larry R Jackson
- Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Colin Marts
- Duke University School of Medicine, Durham, NC
| | | | - Angie Wu
- Duke Clinical Research Institute, Durham, NC
| | | | | | - Sreekanth Vemulapalli
- Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Kevin L Thomas
- Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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25
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Fleury MA, Clavel MA. Sex and Race Differences in the Pathophysiology, Diagnosis, Treatment, and Outcomes of Valvular Heart Diseases. Can J Cardiol 2021; 37:980-991. [PMID: 33581193 DOI: 10.1016/j.cjca.2021.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/20/2021] [Accepted: 02/03/2021] [Indexed: 12/22/2022] Open
Abstract
Valvular heart diseases have long been considered to be similar in men and women and across races/ethnicities. Recently, studies have demonstrated major differences between sexes. Unfortunately, studies on valvular heart diseases, as on other cardiovascular diseases, are mostly performed in Caucasian men or in cohorts with a vast majority of Caucasian men. Therefore, our knowledge on valvular diseases in women and non-Caucasians remains limited. Nevertheless, aortic stenosis has been shown to be almost as prevalent in women as in men, and less prevalent in African Americans. Men appear to have a more calcified aortic valve lesion, and women tend to have a more fibrosed one. Primary mitral regurgitation is more frequent in women who have more rheumatic and Barlow etiologies, whereas men have more fibroelastic deficiency and posterior leaflet prolapse/flail. Left ventricular remodelling due to valvular heart diseases is sex related in terms of geometry and probably also in composition of the tissue. Outcomes seem to be worse in women after surgical interventions and better than or equivalent to men after transcatheter ones. Regarding other valvular heart diseases, very few studies are available: Aortic regurgitation is more frequent in men, isolated tricuspid regurgitation more frequent in women. Rheumatic valve diseases are more frequent in women and are mostly represented by mitral and aortic stenoses. Many other sex/gender- and race/ethnic-specific studies are still needed in epidemiology, pathophysiology, presentation, management, and outcomes. This review aims to report the available data on sex differences and race specificities in valvular heart diseases, with a primary focus on aortic stenosis and mitral regurgitation.
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Affiliation(s)
- Marie-Ange Fleury
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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26
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Hoyler MM, Feng TR, Ma X, Rong LQ, Avgerinos DV, Tam CW, White RS. Insurance Status and Socioeconomic Factors Affect Early Mortality After Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2020; 34:3234-3242. [DOI: 10.1053/j.jvca.2020.03.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022]
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27
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Khan SU, Kalra A, Kapadia SR, Khan MU, Zia Khan M, Khan MS, Mamas MA, Warraich HJ, Nasir K, Michos ED, Alkhouli M. Demographic, Regional, and State-Level Trends of Mortality in Patients With Aortic Stenosis in United States, 2008 to 2018. J Am Heart Assoc 2020; 9:e017433. [PMID: 33070675 PMCID: PMC7763421 DOI: 10.1161/jaha.120.017433] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Aortic stenosis–related mortality might vary across demographic subsets, regions, and states in the United States. Methods and Results We reviewed the death certificate data from the Centers for Disease Control and Prevention Wide‐Ranging OnLine Data for Epidemiologic Research database to examine aortic stenosis–related mortality trends from 2008 to 2018. Crude and age‐adjusted mortality rates (AAMRs) per 100 000 people and annual percentage change with 95% CIs were calculated. Between 2008 and 2018, AAMR reduced from 12.7 to 11.5 (average annual percentage change, −1.0 [95% CI, −1.5 to −0.5]), because of an accelerated decline between 2015 and 2018 (annual percentage change, −4.4 [95% CI, −6.0 to −2.7]). Older (aged >85 years), male, and White patients had higher death rates than younger, female, and non‐White patients, respectively. Although mortality reduction was similar across sexes, significant mortality reduction was limited to White patients only. The AAMRs were higher in rural than urban areas. States with AAMRs >90th percentile were distributed in the West and the Northeast, and <10th percentile in the South. The AAMRs for sex and race were highest in the West and lowest in the South. None of the states located in the Midwest showed a significant reduction in mortality. Mortality remained stable for hospital setting and nursing home/long‐term care facility, except that the number of deaths increased at home and hospice facility since 2014. Conclusions The reduction in mortality in patients with aortic stenosis was not consistent among demographic subsets and states. The substantial public health and economic implications call for determination of underlying clinical and socioeconomic factors to narrow the gap.
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Affiliation(s)
- Safi U Khan
- Department of Medicine West Virginia University Morgantown WV
| | - Ankur Kalra
- Department of Cardiovascular Medicine Heart, Vascular and Thoracic Institute Cleveland Clinic Cleveland OH.,Section of Cardiovascular Research Heart, Vascular and Thoracic Department Cleveland Clinic Akron General Akron OH
| | - Samir R Kapadia
- Department of Cardiovascular Medicine Heart, Vascular and Thoracic Institute Cleveland Clinic Cleveland OH
| | - Muhammad U Khan
- Department of Medicine West Virginia University Morgantown WV
| | | | | | - Mamas A Mamas
- Keele Cardiovascular Research Group Keele University Stoke-on-Trent UK.,Department of Medicine Jefferson University Philadelphia PA
| | | | - Khurram Nasir
- Department of Cardiovascular Medicine Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Erin D Michos
- Division of Cardiology Department of Medicine Johns Hopkins School of Medicine Baltimore MD.,The Ciccarone Center for the Prevention of Cardiovascular Disease Johns Hopkins School of Medicine Baltimore MD
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28
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Racial disparities and democratization of health care: A focus on TAVR in the United States. Am Heart J 2020; 224:166-170. [PMID: 32417548 DOI: 10.1016/j.ahj.2020.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/10/2020] [Indexed: 11/21/2022]
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29
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Harris CM, Khaliq W, Albaeni A, Norris KC. The influence of race in older adults with infective endocarditis. BMC Infect Dis 2020; 20:146. [PMID: 32066397 PMCID: PMC7027119 DOI: 10.1186/s12879-020-4881-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/12/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Age is a risk factor for infective endocarditis, and almost half of diagnosed patients are age ≥ 60 years. Large national studies have not evaluated inpatient mortality and surgical valvular interventions between older White and Black patients hospitalized with infective endocarditis. METHODS We used the Nationwide Inpatient Sample database to identify older adults ≥60 years in North America with a principle diagnosis of infective endocarditis. Multivariate logistic regression was used to compare in-hospital mortality and valvular repairs/replacement between older Black and White patients. RESULTS Of 10,390 adults, age ≥ 60 years hospitalized for infective endocarditis during 2013 and 2014, 7356 were White and 1089 Black. Blacks were younger (mean age: 70.5 ± 0.5 vs. 73.5 ± 0.2 years, p < 0.01), lived in more zip codes with a median annual income <$39,000/yr. (40.4% vs 18.8%, p < 0.01), and had higher co-morbidity burden (Charlson comorbidity score ≥ 3: 54.6% vs 40.7%, p < 0.01). After multivariate adjustment, Blacks had higher odds for in-hospital mortality (Odds Ratio (OR) = 2.0, [Confidence Interval (CI) 1.1-3.8]; p = 0.020), and lower odds for mitral valve repairs/replacements (OR = 0.53, CI: 0.29-0.99, p = 0.049). CONCLUSIONS Blacks age ≥ 60 years hospitalized in North America with infective endocarditis are less likely to undergo mitral valvular repairs/replacement and had higher in-hospital mortality compared to White patients.
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Affiliation(s)
- Ché Matthew Harris
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Division of Hospital Medicine Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Waseem Khaliq
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Division of Hospital Medicine Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Aiham Albaeni
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0570, USA
| | - Keith C Norris
- Department of Internal Medicine, Division of Nephrology, David Geffen School of Medicine, University of California Los Angeles, California, Los Angeles, USA
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30
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Cardiovascular Diseases in Sub-Saharan Africa Compared to High-Income Countries: An Epidemiological Perspective. Glob Heart 2020; 15:15. [PMID: 32489788 PMCID: PMC7218780 DOI: 10.5334/gh.403] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Non-communicable diseases (NCDs) are the second common cause of death in sub-Saharan Africa (SSA) accounting for about 35% of all deaths, after a composite of communicable, maternal, neonatal, and nutritional diseases. Despite prior perception of low NCDs mortality rates, current evidence suggests that SSA is now at the dawn of the epidemiological transition with contemporary double burden of disease from NCDs and communicable diseases. In SSA, cardiovascular diseases (CVDs) are the most frequent causes of NCDs deaths, responsible for approximately 13% of all deaths and 37% of all NCDs deaths. Although ischemic heart disease (IHD) has been identified as the leading cause of CVDs mortality in SSA followed by stroke and hypertensive heart disease from statistical models, real field data suggest IHD rates are still relatively low. The neglected endemic CVDs of SSA such as endomyocardial fibrosis and rheumatic heart disease as well as congenital heart diseases remain unconquered. While the underlying aetiology of heart failure among adults in high-income countries (HIC) is IHD, in SSA the leading causes are hypertensive heart disease, cardiomyopathy, rheumatic heart disease, and congenital heart diseases. Of concern is the tendency of CVDs to occur at younger ages in SSA populations, approximately two decades earlier compared to HIC. Obstacles hampering primary and secondary prevention of CVDs in SSA include insufficient health care systems and infrastructure, scarcity of cardiac professionals, skewed budget allocation and disproportionate prioritization away from NCDs, high cost of cardiac treatments and interventions coupled with rarity of health insurance systems. This review gives an overview of the descriptive epidemiology of CVDs in SSA, while contrasting with the HIC and highlighting impediments to their management and making recommendations.
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31
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Hoyler MM, White RS, Tam CW. Enhanced Recovery After Surgery Protocols May Help Reduce Racial and Socioeconomic Disparities in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:569-570. [DOI: 10.1053/j.jvca.2019.07.144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 12/17/2022]
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32
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Wilson JB, Jackson LR, Ugowe FE, Jones T, Yankey GS, Marts C, Thomas KL. Racial and Ethnic Differences in Treatment and Outcomes of Severe Aortic Stenosis. JACC Cardiovasc Interv 2020; 13:149-156. [DOI: 10.1016/j.jcin.2019.08.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/19/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
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33
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Alkhouli M, Alqahtani F, Holmes DR, Berzingi C. Racial Disparities in the Utilization and Outcomes of Structural Heart Disease Interventions in the United States. J Am Heart Assoc 2019; 8:e012125. [PMID: 31315490 PMCID: PMC6761641 DOI: 10.1161/jaha.119.012125] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Data on race‐ and ethnicity‐based disparities in the utilization and outcomes of structural heart disease interventions in the United States are scarce. Methods and Results We used the National Inpatient Sample (2011‐2016) to examine racial and ethnic differences in the utilization, in‐hospital outcomes, and cost of structural heart disease interventions among patients ≥65 years of age. A total of 106 119 weighted hospitalizations for transcatheter aortic valve replacement, transcatheter mitral valve repair, and left atrial appendage occlusion were included. The utilization rates (defined as the number of procedures performed per 100 000 US people >65 years of age) were higher in whites compared with blacks and Hispanics for transcatheter aortic valve replacement (43.1 versus 18.0 versus 21.1), transcatheter mitral valve repair (5.0 versus 3.2 versus 3.2), and left atrial appendage occlusion (6.6 versus 2.1 versus 3.5), respectively (P<0.001). Black and Hispanic patients had distinctive socioeconomic and clinical risk profiles compared with white patients. There were no significant differences in the adjusted in‐hospital mortality or key complications between patients of white race, black race, and Hispanic ethnicity following transcatheter aortic valve replacement, transcatheter mitral valve repair, or left atrial appendage occlusion. No difference in cost was observed between white and black patients following any of the 3 procedures. However, Hispanic patients incurred modestly higher cost with transcatheter mitral valve repair and left atrial appendage occlusion compared with white patients. Conclusions Racial and ethnic disparities exist in the utilization of structural heart disease interventions in the United States. Nonetheless, adjusted in‐hospital outcomes were comparable among white, black, and Hispanic patients. Further studies are needed to understand the reasons for these utilization disparities.
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Affiliation(s)
- Mohamad Alkhouli
- Division of CardiologyDepartment of MedicineWest Virginia UniversityMorgantownWV
- Department of CardiologyMayo Clinic School of MedicineRochesterMN
| | - Fahad Alqahtani
- Division of CardiologyDepartment of MedicineWest Virginia UniversityMorgantownWV
| | - David R. Holmes
- Department of CardiologyMayo Clinic School of MedicineRochesterMN
| | - Chalak Berzingi
- Division of CardiologyDepartment of MedicineWest Virginia UniversityMorgantownWV
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34
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Alkhouli M, Holmes DR, Carroll JD, Li Z, Inohara T, Kosinski AS, Szerlip M, Thourani VH, Mack MJ, Vemulapalli S. Racial Disparities in the Utilization and Outcomes of TAVR. JACC Cardiovasc Interv 2019; 12:936-948. [DOI: 10.1016/j.jcin.2019.03.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/20/2022]
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35
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Desai R, Parekh T, Singh S, Patel U, Fong HK, Zalavadia D, Savani S, Doshi R, Sachdeva R, Kumar G. Alarming Increasing Trends in Hospitalizations and Mortality With Heyde's Syndrome: A Nationwide Inpatient Perspective (2007 to 2014). Am J Cardiol 2019; 123:1149-1155. [PMID: 30660352 DOI: 10.1016/j.amjcard.2018.12.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/11/2018] [Accepted: 12/19/2018] [Indexed: 12/16/2022]
Abstract
We studied the trends and outcomes of patients with intestinal angiodysplasia-associated gastrointestinal bleeding (Heyde's syndrome [HS]) with aortic stenosis (AS) who underwent surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI). The National Inpatient Sample (2007 to 2014) and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify HS hospitalizations, pertinent co-morbidities, and outcomes of SAVR versus TAVI from 2011 to 2014. The incidence of HS with AS was 3.1%. The trends in hospitalizations and all-cause inpatient mortality showed relative surges of 29.16% (from 48 to 62 per 100,000) and 22.7% (from 3.7 to 4.54 per 100,000) from 2007 to 2014. HS patients were older (mean age ∼80 vs 77 years) females (54.3% vs 52.2%) compared with AS without HS. The all-cause mortality (6.9% vs 4.1%), length of stay (LOS) (∼7.0 vs 5.8 days), and hospitalization charges ($58,519.31 vs $57,598.67) were higher in HS (p<0.001). No differences were reported in all-cause mortality and hospital charges in HS patients who underwent either SAVR or TAVI. However, the TAVI cohort showed lower rates of stroke (1.7% vs 10.0%) and blood transfusion (1.7% vs 11.7%), a shorter LOS (18.3 vs 23.9 days; p<0.001), and more routine discharges (21.7% vs 14.8%, p = 0.01). An older age, male gender, Asian race, congestive heart failure, coagulopathy, fluid and/or electrolytes disorders, chronic pulmonary disease, and renal failure raised the odds of mortality in HS patients. In conclusion, we observed increasing rates of hospitalizations with HS and higher inpatient mortality from 2007 to 2014. The HS patients who underwent TAVI had fewer complications without any difference in the all-cause mortality compared with SAVR.
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Affiliation(s)
- Rupak Desai
- Department of Cardiology, Atlanta VA Medical Center, Decatur, Georgia
| | - Tarang Parekh
- Department of Health Administration, George Mason University, Fairfax, Virginia
| | - Sandeep Singh
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Upenkumar Patel
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York
| | - Hee Kong Fong
- Department of Internal Medicine, University of Missouri-Columbia, Columbia, Missouri
| | - Dipen Zalavadia
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Sejal Savani
- Department of Public Health, New York University, New York, New York
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada School of Medicine, Reno, Nevada
| | - Rajesh Sachdeva
- Department of Cardiology, Atlanta VA Medical Center, Decatur, Georgia; Department of Cardiology, Morehouse School of Medicine, Atlanta, Georgia; Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Gautam Kumar
- Department of Cardiology, Atlanta VA Medical Center, Decatur, Georgia; Department of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
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