Racial differences in the prevalence of severe aortic stenosis

Bicuspid Aortic Valve in Children and Young Adults for Cardiologists and Cardiac Surgeons: State-of-the-Art of Literature Review

Bicuspid aortic valve disease is the most prevalent congenital heart disease, affecting up to 2% of the general population. The presentation of symptoms may vary based on the patient's anatomy of fusion, with transthoracic echocardiography being the primary diagnostic tool. Bicuspid aortic valves may also appear with concomitant aortopathy, featuring fundamental structural changes which can lead to valve dysfunction and/or aortic dilatation over time. This article seeks to give a comprehensive overview of the presentation, treatment possibilities and long-term effects of this condition. The databases MEDLINE, Embase, and the Cochrane Library were searched using the terms "endocarditis" or "bicuspid aortic valve" in combination with "epidemiology", "pathogenesis", "manifestations", "imaging", "treatment", or "surgery" to retrieve relevant articles. We have identified two types of bicuspid aortic valve disease: aortic stenosis and aortic regurgitation. Valve replacement or repair is often necessary. Patients need to be informed about the benefits and drawbacks of different valve substitutes, particularly with regard to life-long anticoagulation and female patients of childbearing age. Depending on the expertise of the surgeon and institution, the Ross procedure may be a viable alternative. Management of these patients should take into account the likelihood of somatic growth, risk of re-intervention, and anticoagulation risks that are specific to the patient, alongside the expertise of the surgeon or centre. Further research is required on the secondary prevention of patients with bicuspid aortic valve (BAV), such as lifestyle advice and antibiotics to prevent infections, as the guidelines are unclear and lack strong evidence.

Racial and Ethnic Differences in the Prevalence of Severe Aortic Stenosis by Echocardiography

BACKGROUND

Understanding the burden of aortic stenosis (AS) across diverse racial and ethnic populations is important to ensure equitable resource allocation. This study explored whether severe AS rate varies by race and ethnicity.

METHODS

The rates of severe AS, stratified by race and ethnicity, were calculated among 615,038 adults with a transthoracic echocardiogram. Logistic regression analysis was performed to identify factors associated with severe AS.

RESULTS

Severe AS rates ranged from 0.08% in adults < 50 years old to 3.8% in those ≥ 90 years old. Compared to non-Hispanic White and Asian American [adjusted odds ratio (aOR) = 0.47, 95% confidence interval (CI): 0.42-0.53] and non-Hispanic Black (aOR = 0.44, 95% CI: 0.39-0.50) patients were less likely to have severe AS, whereas Hispanic patients (aOR = 0.91, 95% CI: 0.87-0.98) had near similar likelihood. Age was the strongest risk factor for severe AS (compared to age < 50 years, aOR = 21.8, 95% CI: 17.8-26.6 for age 80-89 years, and aOR = 43.8, 95% 35.5-54.0 for age ≥ 90 years). Additional factors associated with severe AS included male sex (aOR = 1.38, 95% CI: 1.30-1.46) and diabetes (aOR = 1.23, 95% CI: 1.15-1.31).

CONCLUSIONS

Asian American and non-Hispanic Black adults had lower rates of severe AS compared to White and Hispanic patients. The rate of severe AS progressively increases with age in all racial and ethnic groups, with higher rates in men compared with women. With a demographic shift toward an aging and more diverse population, the burden of AS is anticipated to rise. Ensuring adequate allocation of resources to meet the evolving needs of a diverse population remains a shared health care imperative.

Racial disparities in TAVR outcomes in patients with cancer

Background

Advances in cancer therapies and improvement in survival of cancer patients have led to a growing number of patients with both cancer and severe aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has been shown to be a safe and effective treatment option for this patient population. There are established racial disparities in utilization and outcomes of both cancer treatments and TAVR. However, the effect of race on TAVR outcomes in cancer patients has not been studied.

Objectives

The purpose of this study was to investigate racial disparities in outcomes of TAVR in cancer patients.

Methods

343 patients with cancer who underwent TAVR at a single center over a 6-year period were included in the study. The primary endpoint was a composite of 1-year mortality, stroke, and bleeding. Secondary outcomes included individual components of the primary endpoint as well as 30-day mortality, structural complications, vascular access complications, and conduction system complications. Outcomes were compared between black and white patients by comparing incidence rates.

Results

Baseline characteristics including age, sex, BMI, medical comorbidities, STS score, and echocardiographic parameters were similar between races, aside from significantly higher rates of CKD (50.0% vs. 26.6%, p = 0.005) and ESRD (18.4% vs. 4.9%, p = 0.005) in black compared to white cancer patients. There was a trend toward worse outcomes in black cancer patients with regard to a composite endpoint of 1-year mortality, stroke, and major bleeding (35.7% vs. 22.6%, p = 0.095), primarily driven by higher 1-year mortality (31.0% vs. 17.6%, p = 0.065). 30-day mortality was twice as high in black cancer patients than in white cancer patients (4.8% vs. 2.3%, p = 0.018).

Conclusions

There is a trend toward worse TAVR outcomes in black cancer patients, with higher periprocedural complication rates and mortality, compared to white cancer patients. Further studies are needed to elucidate the structural, socioeconomic, and biological factors that contribute to racial differences in outcomes.

Demographics and mortality trends of valvular heart disease in older adults in the United States: Insights from CDC-wonder database 1999-2019

Background

Valvular heart disease (VHD) represents a spectrum of cardiac conditions, including valvular stenosis, valvular regurgitation, or mixed lesions affecting single or multiple valves. The severity of VHD has emerged as a major cause of cardiovascular (CV) morbidity and mortality among the older population in the United States (U.S).

Objective

To evaluate temporal trends in mortality associated with VHD in the elderly U.S population between 1999 and 2019.

Methods

We utilized the CDC WONDER database for VHD mortality in adults ≥75 from 1999 to 2019, using ICD-10 codes. Age-adjusted mortality rates (AAMR) per 100,000 people with associated annual percentage change (APC) were calculated. Joinpoint regression was used to assess the overall trends and trends for demographic, geographic, and type of valvular disease subgroups.

Results

A total of 666,765 VHD deaths in older adults from 1999 to 2019 was identified, with an initial decline in AAMR until 2007 with an APC: 0.62, 95 % CI (-1.66-0.33), stability until 2014, and a significant decrease until 2019 (APC: 1.47, 95 % CI [-2.24-1.04], P < 0.0001). Men consistently had higher AAMRs compared to women (overall AAMR men: 173.6; women: 138.2). The AAMRs were found to be highest in the White (166.5), followed by American Indian or Alaska Native population at (93.8) Hispanic or Latino at (80.7), Black or African American populations at (74.1) and lastly Asian or Pacific Islander (73.4). Non-metropolitan areas manifested higher AAMRs for deaths related to VHD than metropolitan areas (overall AAMRs 160.5 vs 149.5) respectively. State-wide AAMRs varied, with the highest in Vermont at 324.2 (95 % CI [313.0-335.4], P < 0.0001) and the lowest in Mississippi at 88.0 (95 % CI [85.0-91.0], P < 0.0001). Non-rheumatic and aortic valve disorders in adults ≥75 years had higher mortality rates compared to rheumatic or mitral valve conditions in those <75 years.

Conclusion

Our study showed a decline in U.S. VHD mortality from 1999 to 2019 but found persistent disparities by gender, race, age, region, and VHD type. Targeted policies for prevention and early diagnosis are needed to address these inequalities.

Unraveling the Mechanisms of Valvular Heart Disease to Identify Medical Therapy Targets: A Scientific Statement From the American Heart Association

Valvular heart disease is a common cause of morbidity and mortality worldwide and has no effective medical therapy. Severe disease is managed with valve replacement procedures, which entail high health care-related costs and postprocedural morbidity and mortality. Robust ongoing research programs have elucidated many important molecular pathways contributing to primary valvular heart disease. However, there remain several key challenges inherent in translating research on valvular heart disease to viable molecular targets that can progress through the clinical trials pathway and effectively prevent or modify the course of these common conditions. In this scientific statement, we review the basic cellular structures of the human heart valves and discuss how these structures change in primary valvular heart disease. We focus on the most common primary valvular heart diseases, including calcific aortic stenosis, bicuspid aortic valves, mitral valve prolapse, and rheumatic heart disease, and outline the fundamental molecular discoveries contributing to each. We further outline potential therapeutic molecular targets for primary valvular heart disease and discuss key knowledge gaps that might serve as future research priorities.

Racial and Ethnic Disparities in Peri-and Post-operative Cardiac Surgery

Purpose of Review

Despite efforts to curtail its impact on medical care, race remains a powerful risk factor for morbidity and mortality following cardiac surgery. While patients from racial and ethnic minority groups are underrepresented in cardiac surgery, they experience a disproportionally elevated number of adverse outcomes following various cardiac surgical procedures. This review provides a summary of existing literature highlighting disparities in coronary artery bypass surgery, valvular surgery, cardiac transplantation, and mechanical circulatory support.

Recent Findings

Unfortunately, specific causes of these disparities can be difficult to identify, even in large, multicenter studies, due to the complex relationship between race and post-operative outcomes. Current data suggest that these racial/ethnic disparities can be attributed to a combination of patient, socioeconomic, and hospital setting characteristics.

Summary

Proposed solutions to combat the mechanisms underlying the observed disparate outcomes require deployment of a multidisciplinary team of cardiologists, anesthesiologists, cardiac surgeons, and experts in health care equity and medical ethics. Successful identification of at-risk populations and the implementation of preventive measures are necessary first steps towards dismantling racial/ethnic differences in cardiac surgery outcomes.

Race, neighborhood disadvantage, and survival of Medicare beneficiaries after aortic valve replacement and concomitant coronary artery bypass grafting

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.

Racial/Ethnic Disparities in Aortic Valve Replacement Among Medicare Beneficiaries in the United States, 2012-2019

PURPOSE

There are concerns that transcatheter or surgical aortic valve replacement (TAVR/SAVR) procedures are preferentially available to White patients. Our objective was to examine differences in utilization of aortic valve replacement and outcomes by race/ethnicity in the US for patients with aortic stenosis.

METHODS

We performed a serial cross-sectional cohort study of 299,976 Medicare beneficiaries hospitalized with principal diagnosis of aortic stenosis between 2012 and 2019 stratified by self-reported race/ethnicity (Black, Hispanic, Asian, Native American, and White). Outcomes included aortic valve replacement rates within 6 months of index hospitalization and associated procedural outcomes, including 30-day readmission, 30-day and 1-year mortality.

RESULTS

Within 6 months of an index admission for aortic stenosis, 86.8% (122,457 SAVR; 138,026 TAVR) patients underwent aortic valve replacement. Overall, compared with White people, Black (HR 0.87 [0.85-0.89]), Hispanic (0.92 [0.88-0.96]), and Asian (0.95 [0.91-0.99]) people were less likely to receive aortic valve replacement. Among patients who were admitted emergently/urgently, White patients (41.1%, 95% CI, 40.7-41.4) had a significantly higher aortic valve replacement rate compared with Black (29.6%, 95% CI, 28.3-30.9), Hispanic (36.6%, 95% CI, 34.0-39.3), and Asian patients (35.4%, 95% CI, 32.3-38.9). Aortic valve replacement rates increased annually for all race/ethnicities. There were no significant differences in 30-day or 1-year mortality by race/ethnicity.

CONCLUSIONS

Aortic valve replacement rates within 6 months of aortic stenosis admission are lower for Black, Hispanic, and Asian people compared to White people. These race-related differences in aortic stenosis treatment reflect complex issues in diagnosis and management, warranting a comprehensive reassessment of the entire care spectrum for disadvantaged populations.

Temporal trends in the utilization and outcome of transcatheter aortic valve replacement across racial and ethnic groups. A nationwide analysis

BACKGROUND

Transcatheter aortic valvular replacement (TAVR) improves outcomes in patients with aortic stenosis (AS). However, data describing racial disparities in the utilization and outcomes of TAVR are limited. We aimed to evaluate the utilization trends and outcomes of TAVR across racial and ethnic groups.

METHODS

All patients who underwent TAVR in the United States from 2016 through 2020 were identified from the National Inpatient Sample database. Patients were classified according to their racial and ethnic groups as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, and Asian. We assessed racial and ethnic differences in the outcomes of TAVR using multivariate logistic regression analysis adjusting for age, sex, insurance, income, hospital location and teaching status, bed size, region, and the Charlson Comorbidity Index.

RESULTS

Of the 280,290 patients who underwent TAVR, 89.5% were NHW, 4.24% were NHB, 4.9% were Hispanic, and 1.39% were Asian people. In 2016, the rates of all-TAVR procedures were 1.48 per 1000 patients among NHW group but 0.39 in NHB, 0.4 in Hispanic, and 0.47 in the Asian group. A steep rise was noted in the rate of TAVR among NHW but not in the NHB, Hispanic, and Asian groups. NHB patients had lower mortality rates (adjusted Odds Ratio [aOR]: 0.56; CI 0.35-0.88 p = 0.014) compared to their NHW counterparts.

CONCLUSION

The racial and ethnic gap in the utilization of TAVR widened during the study period with minority groups being disproportionately less likely to receive TAVR. NHB patients who received TAVR had lower mortality rates than NHW.

Independent association of aortic stenosis with many known cardiovascular risk factors and many inflammatory diseases

BACKGROUND

Aortic valve stenosis is associated with age, rheumatic fever and bicuspid aortic valve, but its association with other co-morbidities, such as inflammatory disease and race/ethnicity, is less known.

AIM

To investigate any association between aortic stenosis and many co-morbidities.

METHODS

We used the large Nationwide Inpatient Sample database to evaluate any association between aortic stenosis and risk factors. We performed univariate and multivariable analyses, adjusting for co-morbid conditions.

RESULTS

Data were extracted from the first available database that used the International Classification of Diseases, Tenth Revision codes specifically coding for aortic stenosis alone, spanning from 2016 to 2020 (n=112,982,565). A total of 2,322,649 patients had aortic stenosis; the remaining 110,659,916 served as controls. We found a strong and independent significant association between aortic stenosis and coronary artery disease (odds ratio [OR]: 2.11, 95% confidence interval [CI]: 2.09-2.13), smoking (OR: 1.08, 95% CI: 1.07-1.08), diabetes mellitus (OR: 1.15, 95% CI: 1.14-1.16), hypertension (OR: 1.41, 95% CI: 1.4-1.42), hyperlipidaemia (OR: 1.31, 95% CI: 1.3-1.32), renal disease (OR: 1.3, 95% CI: 1.29-1.31), chronic obstructive pulmonary disease (OR: 1.05, 95% CI: 1.04-1.05), obesity (OR: 1.3, 95% CI: 1.29-1.32), white race/ethnicity (OR: 1.47, 95% CI: 1.42-1.52), rheumatoid arthritis (OR: 1.13, 95% CI: 1.11-1.15), scleroderma (OR: 1.93, 95% CI: 1.79-2.09), systemic connective tissue disease (OR: 1.24, 95% CI: 1.2-1.27), polyarteritis nodosa (OR: 1.5, CI: 1.24-1.81) and Raynaud's syndrome (OR: 1.16, 95% CI: 1.09-1.24) (all P<0.001), in addition to known factors, such as age, male sex and bicuspid aortic valve.

CONCLUSION

Using a very large database, we found many new associations with aortic valve stenosis, including race/ethnicity, renal disease, several inflammatory diseases, chronic obstructive pulmonary disease and obesity, in addition to many other known cardiovascular risk factors.

Racial Disparity Among Patients Undergoing Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in the United States

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.

Racial, Ethnic, and Gender Disparities in Valvular Heart Failure Management

Racial, ethnic, and gender disparities are present in the diagnosis and management of valvular heart disease. The prevalence of valvular heart disease varies by race, ethnicity, and gender, but diagnostic evaluations are not equitable across the groups, which makes the true prevalence less clear. The delivery of evidence-based treatments for valvular heart disease is not equitable. This article focuses on the epidemiology of valvular heart diseases associated with heart failure and the related disparities in treatment, with a focus on how to improve delivery of nonpharmacological and pharmacological treatments.

Aortic valve intervention rates in patients of different ethnicity with severe aortic stenosis in Leicestershire, UK

OBJECTIVES

To explore the ethnic differences in patients undergoing aortic valve (AV) intervention for severe aortic stenosis (AS) in Leicestershire, UK.

METHODS

Retrospective cohort study of all surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) at a single tertiary centre between April 2017 and March 2022, using local registry data.

RESULTS

Of the 1231 SAVR and 815 TAVI performed, 6.5% and 3.7% were in ethnic minority patients, respectively. Based on the 2011 Census data for those with a Leicestershire postcode, crude cumulative rate of SAVR (n=489) was 0.64 per 1000 population overall and 0.69, 0.46 and 0.36 in White, Asian and Black populations, respectively; and 0.50 per 1000 population overall for TAVI (n=383), with 0.59, 0.16 and 0.06 for White, Asian and Black populations, respectively. Asians undergoing SAVR and TAVI were 5 and 3 years younger, respectively, than white patients with more comorbidities and a worse functional status.The age-adjusted cumulative rates for SAVR were 0.62 vs 0.72 per 1000 population for White and Asian patients and 0.51 vs 0.39 for TAVI. Asians were less likely to undergo SAVR and TAVI than White patients, with a risk ratio (RR) of 0.66 (0.50-0.87) and 0.27 (0.18-0.43), respectively, but the age-adjusted RR was not statistically significant.

CONCLUSION

The crude rates of AV interventions are lower in Asian patients compared with the White population in Leicestershire, although age-adjusted rates were not statistically different. Further research to determine the sociodemographic differences in prevalence, incidence, mechanisms and treatment of AS across the UK is required.

Racial and ethnic differences in aortic stenosis: the tip of the iceberg

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.

Epidemiology and Outcomes of Aortic Stenosis in Acute Decompensated Heart Failure: The ARIC Study

BACKGROUND

Few studies characterize the epidemiology and outcomes of aortic stenosis (AS) in acute decompensated heart failure (ADHF). This study investigates the significance of AS in contemporary patients who have experienced an ADHF hospitalization.

METHODS

The ARIC study (Atherosclerosis Risk in Communities) surveilled ADHF hospitalizations for residents ≥55 years of age in 4 US communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF). Demographic differences in AS burden and the association of varying AS severities with mortality were estimated using multivariable logistic regression.

RESULTS

From 2005 through 2014, there were 3597 (weighted n=16 692) ADHF hospitalizations of which 48.6% had an LVEF <50% and 51.4% an LVEF ≥50%. AS prevalence was 12.1% and 18.7% in those with an LVEF <50% and ≥50%, respectively. AS was less likely in Black than White patients regardless of LVEF: LVEF <50% (odds ratio [OR], 0.34 [95% CI, 0.28-0.42]); LVEF ≥50% (OR, 0.51 [95% CI, 0.44-0.59]). Higher AS severity was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.16 [95% CI, 1.04-1.28]); LVEF ≥50% (OR, 1.40 [95% CI, 1.28-1.54]). Sensitivity analyses excluding severe AS patients detected that mild/moderate AS was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.23 [95% CI, 1.02-1.47]); LVEF ≥50% (OR, 1.31 [95% CI, 1.14-1.51]).

CONCLUSIONS

Among patients who have experienced an ADHF hospitalization, AS is prevalent and portends poor mortality outcomes. Notably, mild/moderate AS is independently associated with 1-year mortality in this high-risk population.

The racial disparity among post transcatheter aortic valve replacement outcomes: A meta-analysis

Background

Racial disparities have been well described in cardiovascular disease. However, the impact of race on the outcomes post - Transcatheter aortic valve replacement (TAVR) remains unknown.

Objective

We aim to evaluate the disparity among the race (black and white) post - TAVR.

Methods

We systematically searched all electronic databases from inception until September 26, 2022. The primary outcome was in-hospital all-cause mortality, and secondary outcomes was myocardial infarction (MI), acute kidney injury (AKI), permanent pacemaker implantation (PPI) or ICD, stroke, vascular complications, and major bleeding.

Results

A total of three studies with 1,02,009 patients were included in the final analysis. The mean age of patients with white and black patients was 82.65 and 80.45 years, respectively. The likelihood of in-hospital all-cause mortality (OR, 1.01(95 %CI: 0.86-1.19), P = 0.93), stroke (OR, 0.83(95 %CI:0.61-1.13), P = 0.23, I2 = 46.57 %], major bleeding [OR, 1.05(95 %CI:0.92-1.20), P = 0.46), and vascular complications [OR, 0.92(95 %CI:0.81-1.06), P = 0.26), was comparable between white and black patients. However, patients with white race have lower odds of MI (OR, 0.65(95 %CI:0.50-0.84), P < 0.001), and AKI (OR, 0.84(95 %CI:0.74-0.95), P = 0.01) and higher odds of PPI or ICD (OR, 1.16(95 %CI: 1.06-1.27), P < 0.001, I2 = 0 %) compared with black race patients.

Conclusion

Our findings suggest disparity post - TAVR outcomes existed, and black patients are at higher risk of MI and AKI than white patients.Key Clinical Message:•What is already known on this topic: Disparity has been witnessed among patients with cardiovascular disease. However, no studies have drawn a significant association among post-TAVR patients' outcomes•What this study adds: Among patients who underwent TAVR, there is a difference in the adverse outcomes between black and white race patients. White patients have a lower risk of post-procedure MI and AKI compared with Black patients.•How this study might affect research, practice, or policy: These disparities need to be addressed, and proper guidelines need to be made along with engaging patients with better medical infrastructure and treatment options..

Application of a Novel Two-Dimensional Echocardiographic Calcium Quantification Method to Assess All Severities of Aortic Stenosis

BACKGROUND

Aortic valve (AV) calcification (AVC) is a strong predictor of aortic stenosis (AS) severity. The two-dimensional AVC (2D-AVC) ratio, a gain-independent ratio composed of the average pixel density of the AV and the aortic annulus, has previously shown strong correlations with two-dimensional (2D) echocardiographic hemodynamic parameters for severe AS and AVC by cardiac computed tomography. We hypothesize that the 2D-AVC ratio correlates with hemodynamic parameters in all severities of AS.

METHODS

A total of 285 patients with a normal AV (n = 49), aortic sclerosis (n = 75), or mild (n = 38), moderate (n = 72), or severe (n = 51) AS undergoing 2D echocardiography were retrospectively evaluated, and the 2D-AVC ratios were correlated to mean AV gradient, peak AV velocity, AV area, and dimensionless index. The 2D-AVC ratios of various AS severities were compared against each other via area under the curve (AUC) analysis.

RESULTS

The 2D-AVC ratio is strongly correlated with mean AV gradient (r = 0.79, P < .0001) and peak AV velocity (r = 0.78, P < .0001). There was moderate correlation with the AV area (r = -0.58, P < .0001) and dimensionless index (r = -0.67, P < .0001) across all AS severities. The 2D-AVC ratio also distinguished nonmoderate AS (mild AS + normal AV) from moderate or greater (moderate + severe) AS (AUC = 0.93) and moderate versus severe AS (AUC = 0.88).

CONCLUSION

The 2D-AVC ratio exhibits moderate to strong correlation with 2D echocardiographic hemodynamic parameters across all severities of AS.

Racial and Ethnic Differences in the Clinical Diagnosis of Aortic Stenosis

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.

Impact of concomitant aortic stenosis on the management and outcomes of acute myocardial infarction hospitalizations in the United States

Objective:

To evaluate the prevalence, management and outcomes of concomitant aortic stenosis (AS) in admissions with acute myocardial infarction (AMI).

Methods:

We used the HCUP-NIS database (2000–2017) to identify adult AMI admissions with concomitant AS. Outcomes of interest included prevalence of AS, in-hospital mortality, use of cardiac procedures, hospitalization costs, length of stay, and discharge disposition.

Results:

Among a total of 11,622,528 AMI admissions, 513,688 (4.4 %) were identified with concomitant AS. Adjusted temporal trends revealed an increase in STEMI and NSTEMI hospitalizations with concomitant AS. Compared to admissions without AS, those with AS were on average older, of female sex, had higher comorbidity, higher rates of NSTEMI (78.9 % vs 62.1 %), acute non-cardiac organ failure, and cardiogenic shock. Concomitant AS was associated with significantly lower use of coronary angiography (45.5 % vs 64.4 %), percutaneous coronary intervention (20.1 % vs 42.5 %), coronary atherectomy (1.7 % vs. 2.8 %) and mechanical circulatory support (3.5 % vs 4.8 %) (all p < 0.001). Admissions with AS had higher rates of coronary artery bypass surgery and surgical aortic valve replacement (5.9 % vs 0.1 %) compared to those without AS. Admissions with AMI and AS had higher in-hospital mortality (9.2 % vs. 6.0 %; adjusted OR 1.12 [95 % CI 1.10–1.13]; p <0.001). Concomitant AS was associated with longer hospital stay, more frequent palliative care consultations and less frequent discharges to home.

Conclusions:

In this 18-year study, an increase in prevalence of AS in AMI hospitalization was noted. Concomitant AS was associated with lower use of guideline-directed therapies and worse clinical outcomes among AMI admissions.

Sex-and race-specific burden of aortic valve calcification among older adults without overt coronary heart disease: The Atherosclerosis Risk in Communities Study

BACKGROUND AND AIMS

The prevalence of aortic valve calcification (AVC) increases with age. However, the sex-and race-specific burden of AVC and associated cardiovascular risk factors among adults ≥75 years are not well studied.

METHODS

We calculated the sex-and race-specific burden of AVC among 2283 older Black and White adults (mean age:80.5 [SD:4.3] years) without overt coronary heart disease from the Atherosclerosis Risk in Communities Study who underwent non-contrast cardiac-gated CT-imaging at visit 7 (2018-2019). Using Poisson regression with robust variance, we calculated the adjusted prevalence ratios (aPR) of the association of AVC with cardiovascular risk factors.

RESULTS

The overall AVC prevalence was 44.8%, with White males having the highest prevalence at 58.2%. The prevalence was similar for Black males (40.5%), White females (38.9%), and Black females (36.8%). AVC prevalence increased significantly with age among all race-sex groups. The probability of any AVC at age 80 years was 55.4%, 40.0%, 37.3%, and 36.2% for White males, Black males, White females, and Black females, respectively. Among persons with prevalent AVC, White males had the highest median AVC score (100.9 Agatston Units [AU]), followed by Black males (68.5AU), White females (52.3AU), and Black females (46.5AU). After adjusting for cardiovascular risk factors, Black males (aPR:0.53; 95%CI:0.33-0.83), White females (aPR:0.68; 95%CI:0.61-0.77), and Black females (aPR:0.49; 95%CI:0.31-0.77) had lower AVC prevalence compared to White males. In addition, systolic blood pressure, non-HDL-cholesterol, and lipoprotein (a) were independently associated with AVC, with no significant race/sex interactions.

CONCLUSIONS

AVC, although highly prevalent, was not universally present in this cohort of older adults. White males had ∼50-60% higher prevalence than other race-sex groups. Moreover, cardiovascular risk factors measured in older age showed significant association with AVC.

Screening Tool to Identify Patients with Advanced Aortic Valve Stenosis

(1) Background: The clinical burden of aortic stenosis (AS) remains high in Western countries. Yet, there are no screening algorithms for this condition. We developed a risk prediction model to guide targeted screening for patients with AS. (2) Methods: We performed a cross-sectional analysis of all echocardiographic studies performed between 2013 and 2018 at a tertiary academic care center. We included reports of unique patients aged from 40 to 95 years. A logistic regression model was fitted for the risk of moderate and severe AS, with readily available demographics and comorbidity variables. Model performance was assessed by the C-index, and its calibration was judged by a calibration plot. (3) Results: Among the 38,788 reports yielded by inclusion criteria, there were 4200 (10.8%) patients with ≥moderate AS. The multivariable model demonstrated multiple variables to be associated with AS, including age, male gender, Caucasian race, Body Mass Index ≥ 30, and cardiovascular comorbidities and medications. C-statistics of the model was 0.77 and was well calibrated according to the calibration plot. An integer point system was developed to calculate the predicted risk of ≥moderate AS, which ranged from 0.0002 to 0.7711. The lower 20% of risk was approximately 0.15 (corresponds to a score of 252), while the upper 20% of risk was about 0.60 (corresponds to a score of 332 points). (4) Conclusions: We developed a risk prediction model to predict patients' risk of having ≥moderate AS based on demographic and clinical variables from a large population cohort. This tool may guide targeted screening for patients with advanced AS in the general population.

Socioeconomic Factors and their Impact on Access and Use of Coronary and Structural Interventions

In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.

Racial, ethnic and socioeconomic disparities in patients undergoing transcatheter mitral edge-to-edge repair

BACKGROUND

Transcatheter mitral edge-to-edge repair (TEER) is an increasingly common procedure performed on patients with severe mitral regurgitation. This study assessed the impact of race/ethnicity and socioeconomic status on in-hospital complications after TEER.

METHODS

Cohort-based observational study using the National Inpatient Sample between October 2013 and December 2018. The population was stratified into 4 groups based on race/ethnicity and quartiles of neighborhood income levels. The primary outcome was in-hospital complications, defined as the composite of death, bleeding, cardiac and vascular complications, acute kidney injury, and ischemic stroke.

RESULTS

3795 hospitalizations for TEER were identified. Patients of Black and Hispanic race/ethnicity comprised 7.4% and 6.4%, respectively. We estimated that White patients received TEER with a frequency of 38.0/100,000, compared to 29.7/100,000 for Blacks and 30.5/100,000 for Hispanics. In-hospital complications occurred in 20.2% of patients and no differences were found between racial/ethnic groups (P = 0.06). After multilevel modelling, Black and Hispanic patients had similar rate of overall in-hospital complications (OR: 0.84, CI:0.67-1.05 and OR: 0.84, CI:0.66-1.07, respectively) as compared to White patients, however, higher rates of death were observed in Black patients. Individuals living in income quartile-1 had worse in-hospital outcomes as compared to quartile-4 (OR: 1.19, CI:0.99-1.42).

CONCLUSION

In this study assessing racial/ethnic disparities in TEER outcomes, aged-adjusted race/ethnicity minorities were less underrepresented as compared to other structural heart interventions. Black patients experienced a higher rate of in-hospital death, but similar overall rate of post-procedural adverse events as compared to White patients. Lower income levels appear to negatively impact on in-hospital outcomes.

BRIEF SUMMARY

This study appraises race/ethnic and socioeconomical disparities in access and outcomes following transcatheter mitral edge-to-edge repair. Racial minority groups were less underrepresented as compared to other structural heart interventions. While Black patients experienced a higher rate of in-hospital death, they experienced similar overall rate of post-procedural complications compared to White patients. Lower income levels also appeared to negatively impact on outcomes.

Racial, Ethnic, and Socioeconomic Disparities in Access to Transcatheter Aortic Valve Replacement Within Major Metropolitan Areas

Importance

Despite the benefits of high-technology therapeutics, inequitable access to these technologies may generate disparities in care.

Objective

To examine the association between zip code-level racial, ethnic, and socioeconomic composition and rates of transcatheter aortic valve replacement (TAVR) among Medicare patients living within large metropolitan areas with TAVR programs.

Design, Setting, and Participants

This multicenter, nationwide cross-sectional analysis of Medicare claims data between January 1, 2012, and December 31, 2018, included beneficiaries of fee-for-service Medicare who were 66 years or older living in the 25 largest metropolitan core-based statistical areas.

Exposure

Receipt of TAVR.

Main Outcomes and Measures

The association between zip code-level racial, ethnic, and socioeconomic composition and rates of TAVR per 100 000 Medicare beneficiaries.

Results

Within the studied metropolitan areas, there were 7590 individual zip codes. The mean (SD) age of Medicare beneficiaries within these areas was 71.4 (2.0) years, a mean (SD) of 47.6% (5.8%) of beneficiaries were men, and a mean (SD) of 4.0% (7.0%) were Asian, 11.1% (18.9%) were Black, 8.0% (12.9%) were Hispanic, and 73.8% (24.9%) were White. The mean number of TAVRs per 100 000 Medicare beneficiaries by zip code was 249 (IQR, 0-429). For each $1000 decrease in median household income, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.2% (95% CI, 0.1%-0.4%) lower (P = .002). For each 1% increase in the proportion of patients who were dually eligible for Medicaid services, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 2.1% (95% CI, 1.3%-2.9%) lower (P < .001). For each 1-unit increase in the Distressed Communities Index score, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.4% (95% CI, 0.2%-0.5%) lower (P < .001). Rates of TAVR were lower in zip codes with higher proportions of patients of Black race and Hispanic ethnicity, despite adjusting for socioeconomic markers, age, and clinical comorbidities.

Conclusions and Relevance

Within major metropolitan areas in the US with TAVR programs, zip codes with higher proportions of Black and Hispanic patients and those with greater socioeconomic disadvantages had lower rates of TAVR, adjusting for age and clinical comorbidities. Whether this reflects a different burden of symptomatic aortic stenosis by race and socioeconomic status or disparities in use of TAVR requires further study.

Distressed Communities Index in Patients Undergoing Transcatheter Aortic Valve Implantation in an Affluent County in New York

Background

The clinical impact of the distressed communities index (DCI), a composite measure of economic well-being based on the U.S. zip code, is becoming increasingly recognized. Ranging from 0 (prosperous) to 100 (distressed), DCI's association with cardiovascular outcomes remains unknown. We aimed to study the association of the DCI with presentation and outcomes in adults with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve intervention (TAVR) in an affluent county in New York.

Methods

The study population included 286 patients with severe symptomatic AS or degeneration of a bioprosthetic valve who underwent TAVR with a newer generation transcatheter heart valve (THV) from December 2015 to June 2018 at an academic tertiary medical center. DCI for each patient was derived from their primary residence zip code. Patients were classified into DCI deciles and then categorized into 4 groups. The primary and secondary outcomes of interest were 30-day, 1-year, and 3-year mortality, respectively.

Results

Among 286 patients studied, 26%, 28%, 28%, and 18% were categorized into DCI groups 1–4, respectively (DCI <10: n = 73; DCI 10–20: n = 81; DCI 20–30: n = 80; DCI >30: n = 52). Patients in group 4 were younger with worse kidney function compared to patients in groups 1 and 2. They also had smaller aortic annuli and were more likely to receive a smaller THV. No significant difference in hospital length of stay or distribution of in-hospital, 30-day, 1-year, and 3-year mortality was demonstrated.

Conclusions

While the DCI was associated with differences in the clinical and anatomic profile, it was not associated with differences in clinical outcomes in this prospective observational study of adults undergoing TAVR suggesting that access to care is the likely discriminator.

Inequities in Aortic Stenosis and Aortic Valve Replacement Between Black/African-American, White, and Hispanic Residents of Maryland

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.

Race/Ethnicity and Prevalence of Aortic Stenosis by Echocardiography in the Multi-Ethnic Study of Atherosclerosis

“At MESA Exam 6, the age-adjusted prevalence of AS is lower in Black (1.8%) and Chinese (0.3%) compared to Hispanic (3.7%) and White participants (3.5%).”

Racial disparities in the treatment of aortic stenosis: Has transcatheter aortic valve replacement bridged the gap?

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.

Temporal trends in utilization and outcomes of transcatheter aortic valve replacement in different races: an analysis of the national inpatient sample

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.

A Twenty-Year Analysis of Demographics, Surgical Management, and Outcomes of Aortic Stenosis in New Jersey

We investigated the incidence and characteristics of 14,996 patients with aortic stenosis (AS) who were hospitalized in New Jersey between the years 1995 to 2015. The average age was 72, the majority were Caucasian males and common co-morbidities were hypertension, coronary artery disease and hypercholesterolemia. Hospital admission for AS declined between 1995 to 2007, to 10/100,000 patients, and increased to 15/100,000 patients in 2015 (p for trend <0.001). During the study period, the percentage of patients who received aortic valve replacement (AVR) increased (p <0.001). All-cause and cardiovascular mortality were higher among patients who did not undergo AVR at 1-year (HR 1.98 CI 1.75 to 2.23, p <0.001 and HR 1.82 CI 1.57 to 2.11, p <0.001, respectively) and 3-years (HR 2.16 CI 1.96 to 2.38, p <0.001 and HR 2.16 CI 1.90 to 2.45, p <0.001, respectively). The probability for readmission for AS was higher in patients who did not receive AVR compared to patients who had AVR at 1 year (HR 92.95 CI 57.85 to 149.35, p <0.001) and 3 years (HR 70.36 CI 47.18 to 104.95, p <0.001). These data imply that earlier diagnosis of AS and AVR when indicated will improve outcomes.

Incidence and Predictors of In-Hospital Mortality Among Diabetics Undergoing Transcatheter Aortic Valve Replacement

Objectives

The main goals of this study are to delineate the differences in demographics, comorbidities and hospital outcomes between diabetic and non-diabetic aortic stenosis (AS) patients, and next is to evaluate the predictors of in-hospital mortality in AS patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

We conducted an observational cross-sectional study using the nationwide inpatient sample (NIS) and included 33,325 adult patients with a primary discharge diagnosis of AS who underwent TAVR during the hospitalization. This sample was further grouped by comorbid diabetic which include non-diabetics (N = 23,585) versus diabetic patients (N = 9,740). Among the hospital outcomes we included the length of stay (LOS) and total cost during hospitalization, and the all-cause in-hospital mortality. We used an independent logistic regression model adjusted for demographic confounders to measure the adjusted odds ratio (aOR) of association of comorbid medical conditions and in-hospital mortality risk in non-diabetic and diabetic groups.

Results

The most prevalent medical comorbidities among inpatients with diabetes were hypertension (85.1%), followed by renal failure (38.0%), chronic lung disease (37.1%), obesity (21.3%), and these values were significantly higher compared with the non-diabetic group. The in-hospitality mortality was higher among the non-diabetic group (4.7%) compared to the diabetic group (2.8%). There was no significant difference in mean length of stay and mean total cost between the diabetic and non-diabetic groups. In diabetic AS inpatients, stroke (aOR: 4.58, 95%CI: 2.23-9.42) and fluid/electrolyte disorders (aOR: 4.25, 95%CI: 3.29-5.48) had a statistically significant association with mortality risk when compared to the non-diabetic group. Among the non-diabetic AS inpatients, fluid/electrolyte disorders had the highest mortality risk (aOR: 2.48, 95% CI 2.17-2.83) followed by coagulopathy (aOR: 2.03; CI: 1.77-2.32), congestive heart failure (aOR: 1.67; CI: 1.40-1.98), and renal failure (aOR: 1.62; CI: 1.41-1.86). Meanwhile, hypertension and obesity had a statistically non-significant and negative association with in-hospital mortality in diabetic and non-diabetic groups.

Conclusions

Diabetic AS inpatients following TAVR had a higher mortality risk with comorbid fluid/electrolyte disorders and stroke. In-hospital mortality following TAVR was lower among the diabetics compared to non-diabetics, and it underscores diabetes as a surgical risk factor in patients with AS. So, TAVR may be the preferred approach for diabetic patients with AS along with cardiovascular risk factor modification, strict glycemic control and timely renal function follow-up.

Racial and ethnic disparities in the use of transcatheter aortic valve replacement in the State of Connecticut

BACKGROUND

Although prior national reports have identified trends in the underutilization of transcatheter aortic valve replacement (TAVR) in Afro-American and Latino populations, racial and ethnic healthcare disparities in TAVR use in the State of Connecticut have not been previously reported.

METHODS

We conducted a retrospective analysis of 1461 patients undergoing TAVR at our institute between from 2012 to 2020. Baseline demographics, procedural characteristics, clinical outcomes, median incomes and insurance coverage were compared between 1417 Caucasian and 44 minority patients, including 23 patients designated as Afro-American and 10 designated as Latino. Demographics of TAVR utilization at our institution were further compared to 6 additional Connecticut TAVR centers using Connecticut Hospital Association (CHA) ChimeData detailing hospital discharges for DRG 266 and 267.

RESULTS

In comparison to Caucasian patients, minority cohorts were younger (75.7 ± 9.0 vs 81.5 ± 5.1 years, p < 0.001) and had more co-morbidities including diabetes (64% vs 34%, p < 001), coronary artery disease (95% vs 78%, p = 0.039), end stage renal disease requiring dialysis (9% vs 3%, p = 0.009) and atrial fibrillation (77% vs 62%, p = 0.041). The two groups did not differ with respect to other risk factors or co-morbidities, baseline echocardiographic or CTA findings, STS risk score, or procedural technique. Minority patients had a longer length of hospital stay (9.5 ± 9.0 vs 6.4 ± 6.9 days, p = 0.003), but did not differ with respect to procedural complications. Socioeconomic differences between the two groups included lower median incomes and higher rates of Medicaid or no insurance coverage for minority versus Caucasian patients. CHA ChimeData revealed a similar underutilization of TAVR in minority subgroups in the remaining 6 Connecticut TAVR centers.

CONCLUSIONS

Despite statewide demographics describing 10.7% and 15.7% of the total population as Afro-American and Latino, respectively, only 3.0% of the total TAVR procedures performed at a large Connecticut health care facility were performed in minority subgroups. Despite having a higher burden of co-morbidities, minority patients had similar outcomes compared to Caucasian patients. Similar racial and ethnic disparities in TAVR utilization were confirmed statewide using CHA ChimeData.

Cumulative burden of clinically significant aortic stenosis in community-dwelling older adults

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.

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease

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.

Contemporary trends in the management of aortic stenosis in the USA

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.

Pre-procedural barriers to accessing novel treatments for aortic stenosis among racial/ethnic minorities in the veterans affairs healthcare system

Background

Novel structural heart procedures offer life-saving treatment advantages, yet little is known about pre-procedural barriers to care by race/ethnicity.

Methods

All echocardiograms performed at a Veterans Affairs hospital from 2015 to 2019 were reviewed to identify patients with severe aortic stenosis and their access to transcatheter aortic valve replacement (TAVR) by race/ethnicity.

Results

From 19,403 echocardiograms, 355 individuals were identified to have severe aortic stenosis (72.6% White, 9.8% Hispanic, 3.9% Black). There was a non-significant trend towards increased TAVR treatment among White compared to non-White patients (OR 2.02, CI 0.96-4.24, p = 0.063), which attenuated after adjustment for age and comorbidities. Reasons for not undergoing replacement included poor procedural candidacy (25.3%), loss of follow-up (17.8%), and patient refusal (16.4%).

Conclusions

Racial/ethnic inequities were not detected in novel structural heart treatment within the VA. However, a high proportion of eligible patients did not receive procedural treatment due to patient refusal or loss of follow-up, highlighting barriers that require further study.

Improvements in global longitudinal strain after transcatheter aortic valve replacement according to race

OBJECTIVE

In the United States, racial minorities are underrepresented among patients receiving transcatheter aortic valve replacement (TAVR) and data regarding their outcomes is limited. Global longitudinal strain (GLS) is a measure left ventricular function and has independently predicted outcomes after TAVR. The aim of this study is to assess changes in GLS after TAVR according to race and factors predicting these changes.

METHODS

Electronic medical records of patients undergoing TAVR at the University of Illinois, Chicago and Jesse Brown Veteran's Administration Medical Center (Chicago, Illinois) from January 2017-February 2020 were reviewed retrospectively. The most recent transthoracic echocardiogram (TTE) prior to TAVR and the TTE 1-month post-procedure were used to determine GLS. Patients were included if both a pre- and post-procedure study were present and TTE images were of sufficient quality to process strain imaging.

RESULTS

A total of 103 patients (average age 76 ± 12 years, 80% male, 42% white) were included. At 1-month post-TAVR, GLS improved for all races: white (-2.7 ± 3.5%, P<0.001), African-American (-2.8 ± 3.3%, P<0.001), and Hispanic (-2.0 ± 2.1%, P<0.001). There were no differences in the degree of improvement among races (P=0.62). Baseline GLS was negatively correlated with changes in GLS overall (r=-0.44, P<0.001). Baseline aortic valve area (cm²) was positively correlated with changes in GLS (r=0.2, P=0.036).

CONCLUSIONS

This study demonstrated that GLS improved after TAVR independent of race with similar degrees of change across races. Baseline GLS and aortic valve area predicted strain improvement after TAVR, which suggests that those with more impaired LV function may benefit most from the procedure.

African American-Caucasian American differences in aortic valve replacement in patients with severe aortic stenosis

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.

Expansion of transcatheter aortic valve replacement in the United States

BACKGROUND

Patterns of diffusion of TAVR in the United States (U.S.) and its relation to racial disparities in TAVR utilization remain unknown.

METHODS

We identified TAVR hospitals in the continental U.S. from 2012-2017 using Medicare database and mapped them to Hospital Referral Regions (HRR). We calculated driving distance from each residential ZIP code to the nearest TAVR hospital and calculated the proportion of the U.S. population, in general and by race, that lived <100 miles driving distance from the nearest TAVR center. Using a discrete time hazard logistic regression model, we examined the association of hospital and HRR variables with the opening of a TAVR program.

RESULTS

The number of TAVR hospitals increased from 230 in 2012 to 540 in 2017. The proportion of the U.S. population living <100 miles from nearest TAVR hospital increased from 89.3% in 2012 to 94.5% in 2017. Geographic access improved for all racial and ethnic subgroups: Whites (84.1%-93.6%), Blacks (90.0%- 97.4%), and Hispanics (84.9%-93.7%). Within a HRR, the odds of opening a new TAVR program were higher among teaching hospitals (OR 1.48, 95% CI 1.16-1.88) and hospital bed size (OR 1.44, 95% CI 1.37-1.52). Market-level factors associated with new TAVR programs were proportion of Black (per 1%, OR 0.78, 95% CI 0.69-0.89) and Hispanic (per 1%, OR 0.82, 95% CI 0.75-0.90) residents, the proportion of hospitals within the HRR that already had a TAVR program (per 10%, OR 1.07, 95% CI 1.03-1.11), P <.01 for all.

CONCLUSION

The expansion of TAVR programs in the U.S. has been accompanied by an increase in geographic coverage for all racial subgroups. Further study is needed to determine reasons for TAVR underutilization in Blacks and Hispanics.

Prevalence and Prognostic Significance of Mitral Regurgitation in Acute Decompensated Heart Failure: The ARIC Study

OBJECTIVES

This study investigates the prevalence and prognostic significance of mitral regurgitation (MR) in acute decompensated heart failure (ADHF) patients.

BACKGROUND

Few studies characterize the burden of MR in heart failure.

METHODS

The ARIC (Atherosclerosis Risk In Communities) study surveilled ADHF hospitalizations for residents ≥55 years of age in 4 U.S. communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF): <50% and ≥50%. Odds of moderate or severe MR in patients with varying sex and race, and odds of 1-year mortality in those with higher MR severity were estimated using multivariable logistic regression.

RESULTS

From 2005 to 2014, there were 17,931 weighted ADHF hospitalizations of which 49.2% had an LVEF <50% and 50.8% an LVEF ≥50%. Moderate or severe MR prevalence was 44.5% in those with an LVEF <50% and 27.5% in those with an LVEF ≥50%. Moderate or severe MR was more likely in females than males regardless of LVEF; LVEF <50% (odds ratio [OR]: 1.21 [95% confidence interval (CI): 1.11 to 1.33]), LVEF ≥50% (OR: 1.52 [95% CI: 1.36 to 1.69]). Among hospitalizations with an LVEF ≥50%, moderate or severe MR was less likely in blacks than whites (OR: 0.72 [95% CI: 0.64 to 0.82]). Higher MR severity was independently associated with increased 1-year mortality in those with an LVEF <50% (OR: 1.30 [95% CI: 1.16 to 1.45]).

CONCLUSIONS

Patients with ADHF have a significant MR burden that varies with sex and race. In ADHF patients with an LVEF <50%, higher MR severity is associated with excess 1-year mortality.

Unexpectedly Low Natriuretic Peptide Levels in Patients With Heart Failure

OBJECTIVES

The purpose of this study was to determine the frequency of unexpectedly low natriuretic peptide (NP) levels in a clinical population.

BACKGROUND

Higher NP concentrations are typically observed as a compensatory response to elevated cardiac wall stress. Under these conditions, low NP levels may be indicative of a "NP deficiency."

METHODS

We identified 3 clinical scenarios in which high B-type natriuretic peptide (BNP) levels would be expected: 1) hospitalization for heart failure (HF); 2) abnormal cardiac structure or function; or 3) abnormal hemodynamics. In Vanderbilt's electronic health record, 47,970 adult patients had BNP measurements. A total of 13,613 patients had at least 1 of the 3 conditions (hospitalized HF, n = 9,153; abnormal cardiac structure/function, n = 7,041; abnormal hemodynamics, n = 363). We quantified the frequency of low BNP levels. We performed whole exome sequencing of the NPPB gene in a subset of 9 patients.

RESULTS

Very low BNP levels (<50 pg/ml) were observed in 4.9%, 14.0%, and 16.3% of patients with hospitalized HF, abnormal cardiac structure/function, or abnormal hemodynamics, respectively. A small proportion (0.1% to 1.1%) in each group had BNP levels below detection limits. Higher body mass index was the strongest predictor of unexpectedly low BNP. Exome sequencing did not reveal coding variation predicted to alter detection of BNP by clinical assays.

CONCLUSIONS

A subset of patients with confirmed HF or cardiac dysfunction have unexpectedly low BNP levels. Obesity is the strongest correlate of unexpectedly low BNP levels. Our findings support the possible existence of NP deficiency, which may render some individuals more susceptible to volume or pressure overload.