Disparities in Cardiovascular Risk Factors in Northern Plains American Indians Undergoing Coronary Artery Bypass Grafting

Underutilization of Transcatheter Aortic Valve Replacement in Northern Plains American Indians with Severe Aortic Stenosis

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement and revolutionized the treatment strategy for aortic valve replacement. Little is known on the disparities among minorities, especially American Indians (AI), undergoing this procedure. We explore TAVR outcomes to identify disparities at our institution.

METHODS

Retrospective chart review was completed on patients who underwent TAVR at a North Dakota community hospital between 2012 and 2021. There were 1133 non-AI and 20 AI patients identified (n = 1153). AI patients were identified by enrollment in nationally recognized tribes, Indian Health Service (IHS), or who self-identified as AI. Patient demographics, preoperative characteristics, procedural information, and outcomes were collected. United States 2020 census data was used for state-wide population racial percentages. Unpaired two tail t test assuming unequal variance and chi-squared tests were used to evaluate data and identify disparities between AI and non-AI.

RESULTS

AI presented at an earlier age (71 vs. 79; p = .001) with higher rates of diabetes (60% vs. 35%; p = .018) and history of smoking (100% vs. 60%; p ≤ .001) than Caucasian/white (C/W). The Society of Thoracic Surgery (STS) risk scores (3.2% vs. 4.6%; p = .054) and aortic valve mean gradients were lower among AI (42.8 mmHg vs. 47.5 mmHg; p = .010). For those deceased, AI had significantly shorter lifespans post-TAVR compared to C/W (374 days vs. 755 days; p = .004). AI from North Dakota had fewer TAVR procedures performed than expected (4 actual vs. 32 expected; p < .001).

CONCLUSIONS

AI undergoing TAVR presented earlier, with higher rates of diabetes and smoking, lower STS risk scores, and lesser aortic valve gradients than C/W. The number of TAVR procedures performed on AI from North Dakota was lower than anticipated despite a nearly 10-year period and the disparities experienced by AI who could have otherwise benefited from TAVR.

Native Americans have comparable transcatheter aortic valve replacement outcomes but higher stroke and venous thromboembolism after surgical aortic valve replacement

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.

Post-operative outcomes in Indigenous patients in North America and Oceania: A systematic review and meta-analysis

Indigenous Peoples across North America and Oceania experience worse health outcomes compared to non-Indigenous people, including increased post-operative mortality. Several gaps in data exist regarding global differences in surgical morbidity and mortality for Indigenous populations based on geographic locations and across surgical specialties. The aim of this study is to evaluate disparities in post-operative outcomes between Indigenous and non-Indigenous populations. This systematic review and meta-analysis was conducted in accordance with PRISMA and MOOSE guidelines. Eight electronic databases were searched with no language restriction. Studies reporting on Indigenous populations outside of Canada, the USA, New Zealand, or Australia, or on interventional procedures were excluded. Primary outcomes were post-operative morbidity and mortality. Secondary outcomes included reoperations, readmission rates, and length of hospital stay. The Newcastle Ottawa Scale was used for quality assessment. Eighty-four unique observational studies were included in this review. Of these, 67 studies were included in the meta-analysis (Oceania n = 31, North America n = 36). Extensive heterogeneity existed among studies and 50% were of poor quality. Indigenous patients had 1.26 times odds of post-operative morbidity (OR = 1.26, 95% CI: 1.10-1.44, p<0.01) and 1.34 times odds of post-operative infection (OR = 1.34, 95% CI: 1.12-1.59, p<0.01) than non-Indigenous patients. Indigenous patients also had 1.33 times odds of reoperation (OR = 1.33, 95% CI: 1.02-1.74, p = 0.04). In conclusion, we found that Indigenous patients in North American and Oceania experience significantly poorer surgical outcomes than their non-Indigenous counterparts. Additionally, there is a low proportion of high-quality research focusing on assessing surgical equity for Indigenous patients in these regions, despite multiple international and national calls to action for reconciliation and decolonization to improve quality surgical care for Indigenous populations.

Health Inequities in Coronary Artery Bypass Grafting Literature: A Scoping Review

Although life saving, health inequities exist regarding access and patient outcomes in Coronary artery bypass grafting (CABG), especially among marginalized groups. This scoping review's goal is to outline existing literature and highlight gaps for future research. Researchers followed guidance from the Joanna Briggs Institute and PRISMA extension for scoping reviews. We conducted a search to identify articles published between 2016 and 2022 regarding CABG and inequity groups, defined by the National Institutes of Health. Fifty-seven articles were included in our final sample. Race/Ethnicity was examined in 39 incidences, Sex or Gender 29 times, Income 17 instances, Geography 10 instances, and Education Level 3 instances. Occupation Status 2 instances, and LGBTQ+ 0 times. Important disparities exist regarding CABG access and outcomes, especially involving members of the LGBTQ+, Native American, and Black communities. Further research is needed to address health disparities and their root causes for focused action and improved health of minoritized groups.

Disparities in Secondary Prevention of Atherosclerotic Heart Disease After Coronary Artery Bypass Grafting in Northern Plains American Indians

Introduction: Cardiovascular disease has become the leading cause of death in American Indians (AIs). For patients with severe disease requiring coronary artery bypass grafting (CABG), AIs have been demonstrated to present with increased risk factors. Guideline-directed medical therapy after CABG effectively reduces mortality and recurrent ischemic events in all patients and is especially important in high-risk populations such as AIs. Methods: Isolated CABG patients between 2012 and 2017 were studied and 74 AI patients were identified. Propensity matching was performed and the resulting 148 patients were followed for a year after surgery. Guideline-directed medical therapy (GDMT) for secondary prevention of atherosclerotic disease after CABG was detailed in all patients. Results: GDMT was similar between groups (85% AI vs. 89% non-AI; p=NS), and the incidence of prescribed antiplatelet medications, beta-blockers, and statins was similar. AIs were more likely to receive insulin therapy (p=0.002) and opioids (p=0.03) at discharge, while non-AIs were more likely to receive anti-arrhythmic medications (p=0.002). One year after discharge, GDMT trended lower in AIs (75% AI vs. 85% non-AI; p=0.2) and AIs were less likely to be on a statin 1 year after surgery (81% AI vs. 93% non-AI; p=0.04). Opioid use trended higher after 1 year in AIs (28% AI vs. 18% non-AI; p=NS) and fewer AI patients participated in cardiac rehabilitation (CR) after CABG. Conclusions: Disparities in GDMT for secondary prevention of coronary artery disease after CABG exist, with fewer AI patients receiving statins and undergoing CR 1 year after surgery. Increased use of opioids in AIs is troubling and deserves further investigation. Improved adherence to GDMT would be expected to improve long-term outcomes after CABG in this high risk population.