Fifteen-Year Trends in Management and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Among Black and White Patients: The ARIC Community Surveillance Study, 2000-2014

Gender, racial and ethnic disparities in acute coronary syndromes with coronary in-stent restenosis

Background

Coronary in-stent restenosis (ISR) is a major clinical challenge of contemporary percutaneous revascularization and portends adverse cardiovascular outcomes.

Objectives

We aimed to evaluate gender, race, and ethnicity related outcomes in acute coronary syndromes (ACS) with ISR.

Methods

Primary hospitalizations for ACS and ISR in the National Inpatient Sample database from 2016 to 2019 were included. Patients were stratified by gender, race, and ethnicity. The primary end points were all cause in-hospital mortality and coronary revascularization defined as composite of percutaneous coronary intervention (PCI), balloon angioplasty and/or coronary artery bypass grafting (CABG).

Results

During the study period, a nationally weighted total of 97,680 patients with ACS and ISR were included. There was substantial variation in comorbidities, with greatest burden among Black and Hispanic women. All-cause in-hospital mortality was 2.4 % in the study cohort, but significantly higher in women (2.1 % vs. 2.1 %; aOR: 1.282, 95 % CI: 1.174-1.4; p < 0.001) and revascularization rates were significantly lower in women (77 % vs 80.2 %; aOR: 0.891, 95 % CI: 0.862-0.921; p < 0.001). Compared to White men, all women except Hispanic women, had significantly higher likelihood of in-hospital mortality, while White women, Black men and women, and Hispanic men had lower odds of revascularization.

Conclusions

There are significant gender, racial, and ethnic related differences in revascularization practices and clinical outcomes in patients with ACS and ISR with an adverse impact on women, racial and ethnic minorities in the U.S.

Does Implicit Racial Bias Affect Auditory-Perceptual Evaluations of Dysphonic Voices?

PURPOSE

The purpose of this study was to understand the role of implicit racial bias in auditory-perceptual evaluations of dysphonic voices by determining if a biasing effect exists for novice listeners in their auditory-perceptual ratings of Black and White speakers.

METHOD

Thirty speech-language pathology graduate students at Boston University listened to audio files of 20 Black speakers and 20 White speakers of General American English with voice disorders. Listeners rated the overall severity of dysphonia of each voice heard using a 100-unit visual analog scale and completed the Harvard Implicit Association Test (IAT) to measure their implicit racial bias.

RESULTS

Both Black and White speakers were rated as less severely dysphonic when their race was labeled as Black. No significant relationship was found between Harvard IAT scores and differences in severity ratings by race labeling condition.

CONCLUSIONS

These findings suggest a minimizing bias in the evaluation of dysphonia for Black patients with voice disorders. These results contribute to the understanding of how a patient's race may impact their visit with a clinician. Further research is needed to determine the most effective interventions for implicit bias retraining and the additional ways that implicit racial bias impacts comprehensive voice evaluations.

2022 consensus conference on diversity, equity, and inclusion: Developing an emergency medicine research agenda for addressing racism through health care research

Racism in emergency medicine (EM) health care research is pervasive but often underrecognized. To understand the current state of research on racism in EM health care research, we developed a consensus working group on this topic, which concluded a year of work with a consensus-building session as part of the overall Society for Academic Emergency Medicine (SAEM) consensus conference on diversity, equity, and inclusion: "Developing a Research Agenda for Addressing Racism in Emergency Medicine," held on May 10, 2022. In this article, we report the development, details of preconference methods and preliminary results, and the final consensus of the Healthcare Research Working Group. Preconference work based on literature review and expert opinion identified 13 potential priority research questions that were refined through an iterative process to a list of 10. During the conference, the subgroup used consensus methodology and a "consensus dollar" (contingent valuation) approach to prioritize research questions. The subgroup identified three research gaps: remedies for racial bias and systematic racism, biases and heuristics in clinical care, and racism in study design, and we derived a list of six high-priority research questions for our specialty.

Stem cell therapy for acute myocardial infarction: Mesenchymal Stem Cells and induced Pluripotent Stem Cells

INTRODUCTION

Acute myocardial infarction (AMI) remains a leading cause of death in the United States. The limited capacity of cardiomyocytes to regenerate and the restricted contractility of scar tissue after AMI are not addressed by current pharmacologic interventions. Mesenchymal stem/stromal cells (MSCs) have emerged as a promising therapeutic approach due to their low antigenicity, ease of harvesting, and efficacy and safety in preclinical and clinical studies, despite their low survival and engraftment rates. Other stem cell types, such as induced pluripotent stem cells (iPSCs) also show promise, and optimizing cardiac repair requires integrating emerging technologies and strategies.

AREAS COVERED

This review offers insights into advancing cell-based therapies for AMI, emphasizing meticulously planned trials with a standardized definition of AMI, for a bench-to-bedside approach. We critically evaluate fundamental studies and clinical trials to provide a comprehensive overview of the advances, limitations and prospects for cell-based therapy in AMI.

EXPERT OPINION

MSCs continue to show potential promise for treating AMI and its sequelae, but addressing their low survival and engraftment rates is crucial for clinical success. Integrating emerging technologies such as pluripotent stem cells and conducting well-designed trials will harness the full potential of cell-based therapy in AMI management. Collaborative efforts are vital to developing effective stem cell therapies for AMI patients.

Impact of Diabetes on Outcomes in Patients Hospitalized With Acute Myocardial Infarction: Insights From the Atherosclerosis Risk in Communities Study Community Surveillance

Background Diabetes is associated with increased risk of acute myocardial infarction (AMI). The demographic trends, clinical presentation, management, and outcomes of patients with diabetes who are hospitalized with AMI have not been recently reported. Methods and Results The ARIC (Atherosclerosis Risk in Communities) study conducted hospital surveillance of AMI in 4 US communities. AMI was classified by physician review using a validated algorithm. Medications and procedures were abstracted from the medical record. From 2000 to 2014, 21 094 weighted hospitalizations for AMI were sampled. The prevalence of diabetes steadily increased, from 35% to 41% to 43% (P-trend<0.0001) across 2000 to 2004, 2005 to 2009, and 2010 to 2014, respectively. Patients with diabetes were older (61 versus 59 years of age), more often Black (44% versus 31%), and more commonly women (42% versus 34%). The burden of cardiovascular comorbidities was higher with diabetes and increased temporally. Patients with diabetes less often presented with ST-segment elevation (9% versus 17%) or acute chest pain (72% versus 80%), and had higher mean GRACE (Global Registry of Acute Coronary Syndrome) score (123 versus 109), Thrombolysis in Myocardial Ischemia (TIMI) score (4.3 versus 4.0), and Killip class (1.9 versus 1.5). Patients with diabetes had a lower adjusted probability of receiving aspirin (relative probability, 0.95 [95% CI, 0.91-0.99]), nonaspirin antiplatelets (0.93 [95% CI, 0.86-0.99]), coronary angiography (0.85 [95% CI, 0.78-0.92]), and coronary revascularization (0.85 [95% CI, 0.76-0.92]). Diabetes was associated with a 52% higher hazard of all-cause 1-year mortality (hazard ratio, 1.52 [95% CI, 1.23-1.89]). Conclusions Diabetes is associated with higher risk of death in patients hospitalized with AMI, highlighting the need for adherence to evidence-based therapies in this high-risk population.

Patterns, Predictors, and Intercenter Variability in Empiric Gram-Negative Antibiotic Use Across 928 United States Hospitals

BACKGROUND

Empiric antibiotic use among hospitalized adults in the United States (US) is largely undescribed. Identifying factors associated with broad-spectrum empiric therapy may inform antibiotic stewardship interventions and facilitate benchmarking.

METHODS

We performed a retrospective cohort study of adults discharged in 2019 from 928 hospitals in the Premier Healthcare Database. "Empiric" gram-negative antibiotics were defined by administration before day 3 of hospitalization. Multivariable logistic regression models with random effects by hospital were used to evaluate associations between patient and hospital characteristics and empiric receipt of broad-spectrum, compared to narrow-spectrum, gram-negative antibiotics.

RESULTS

Of 8 017 740 hospitalized adults, 2 928 657 (37%) received empiric gram-negative antibiotics. Among 1 781 306 who received broad-spectrum therapy, 30% did not have a common infectious syndrome present on admission (pneumonia, urinary tract infection, sepsis, or bacteremia), surgery, or an intensive care unit stay in the empiric window. Holding other factors constant, males were 22% more likely (adjusted odds ratio [aOR], 1.22 [95% confidence interval, 1.22-1.23]), and all non-White racial groups 6%-13% less likely (aOR range, 0.87-0.94), to receive broad-spectrum therapy. There were significant prescribing differences by region, with the highest adjusted odds of broad-spectrum therapy in the US West South Central division. Even after model adjustment, there remained substantial interhospital variability: Among patients receiving empiric therapy, the probability of receiving broad-spectrum antibiotics varied as much as 34+ percentage points due solely to the admitting hospital (95% interval of probabilities: 43%-77%).

CONCLUSIONS

Empiric gram-negative antibiotic use is highly variable across US regions, and there is high, unexplained interhospital variability. Sex and racial disparities in the receipt of broad-spectrum therapy warrant further investigation.

Lipid-Lowering Therapy Utilization and Dosage Among Patients with Acute Coronary Syndrome Events: A Retrospective Cohort from 12 Community Hospitals

Introduction

Clinical practice guidelines recommend initiating a high-intensity LLT and continued monitoring of low-density lipoprotein cholesterol (LDL-C) following acute coronary syndrome (ACS). We used real-world data to describe LLT utilization after discharge and 1-year adherence. The reduction in LDL-C was also evaluated.

Methods

Data were extracted from electronic health records (EHRs) from 12 hospitals in a large community healthcare system in midwestern United States between 2013 and 2019. Data on eligible patients recently discharged with an ACS event were linked to pharmacy claims data to describe LLT fill rates and 1-year post-discharge adherence. Adherence was reported as the proportion of days covered ≥80%.

Results

Of the 10,589 eligible patients, 49% filled a high-intensity statin at discharge and only 36% were adherent at 1 year. The mean (SD) age was 66.1±13.3, 39.3% were females, 58.8% were Caucasian, and 53.0% had Medicare. There was a clear trend for greater fill rates at discharge among patients with higher LDL-C values than those with lower values (p<0.01). Key predictors of high-intensity (versus medium-intensity) LLT use within 21 days after an ACS event included ACS type (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.52-0.67 for NSTEMI versus STEMI), age group (OR: 0.59; 95% CI: 0.48-0.72 for >75 years versus <65 years), and statin use before index ACS event (OR: 1.56; 95% CI: 1.23-1.88).

Conclusion

This real-world study found that despite recommendations in clinical practice guidelines, high-intensity LLT fill rates at discharge and 1-year adherence to LLT remain suboptimal. Clinical characteristics, including ACS type and LDL-C values, were strong predictors of filling and adherence to guideline-recommended therapy. Age, sex, and race/ethnicity disparities were observed in discharge fill rates and 1-year adherence. These results highlight the need for continued efforts at the patient and provider levels to improve LLT adherence among ACS patients.

Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study

AIMS

Little is known about ethnic disparities in care and clinical outcomes of patients admitted with non-ST-segment elevation myocardial infarction (NSTEMI) in national cohorts from universal healthcare systems derived from Europe.

METHODS AND RESULTS

We identified 280 588 admissions with NSTEMI in the UK Myocardial Infarction National Audit Project (MINAP), 2010-2017, including White patients (n = 258 364) and Black, Asian, and Minority Ethnic (BAME) patients (n = 22 194). BAME patients were younger (66 years vs. 73 years, P < 0.001) and more frequently had hypertension (66% vs. 54%, P < 0.001), hypercholesterolaemia (49% vs. 34%, P < 0.001), and diabetes (48% vs. 24%, P < 0.001). BAME patients more frequently received invasive coronary angiography (80% vs. 68%, P < 0.001), percutaneous coronary intervention (PCI) (52% vs. 43%, P < 0.001), and coronary artery bypass graft surgery (9% vs. 7%, P < 0.001). Following propensity score matching, BAME compared with White patients had similar in-hospital all-cause mortality [odds ratio (OR) 0.91, confidence interval (CI) 0.76-1.06; P = 0.23], major bleeding (OR 0.99, CI 0.75-1.25; P = 0.95), re-infarction (OR 1.15, CI 0.84-1.46; P = 0.34), and major adverse cardiovascular events (MACE) (OR 0.94, CI 0.80-1.07; P = 0.35).

CONCLUSION

BAME patients with NSTEMI had higher cardiometabolic risk profiles and were more likely to undergo invasive angiography and revascularization, with similar clinical outcomes as those of their White counterparts. Among the quality indicators assessed, there is no evidence of care disparities among BAME patients presenting with NSTEMI.

Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women

PURPOSE OF REVIEW

Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups.

RECENT FINDINGS

There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

Association of Race and Ethnicity on the Management of Acute Non-ST-Segment Elevation Myocardial Infarction

Background

Prior studies have reported disparities by race in the management of acute myocardial infarction (MI), with many studies having limited covariates or now dated. We examined racial and ethnic differences in the management of MI, specifically non–ST‐segment‐elevation MI (NSTEMI), in a large, socially diverse cohort of insured patients. We hypothesized that the racial and ethnic disparities in the receipt of coronary angiography or percutaneous coronary intervention would persist in contemporary data.

Methods and Results

We identified individuals presenting with incident, type I NSTEMI from 2017 to 2019 captured by a health claims database. Race and ethnicity were categorized by the database as Asian, Black, Hispanic, or White. Covariates included demographics (age, sex, race, and ethnicity); Elixhauser variables, including cardiovascular risk factors and other comorbid conditions; and social factors of estimated annual household income and educational attainment. We examined rates of coronary angiography and percutaneous coronary intervention by race and ethnicity and income categories and in multivariable‐adjusted models. We identified 87 094 individuals (age 73.8±11.6 years; 55.6% male; 2.6% Asian, 13.4% Black, 11.2% Hispanic, 72.7% White) with incident NSTEMI events from 2017 to 2019. Individuals of Black race were less likely to undergo coronary angiography (odds ratio [OR], 0.93; [95% CI, 0.89–0.98]) and percutaneous coronary intervention (OR, 0.86; [95% CI, 0.81–0.90]) than those of White race. Hispanic individuals were less likely (OR, 0.88; [95% CI, 0.84–0.93]) to undergo coronary angiography and percutaneous coronary intervention (OR, 0.85; [95% CI, 0.81–0.89]) than those of White race. Higher annual household income attenuated differences in the receipt of coronary angiography across all racial and ethnic groups.

Conclusions

We identified significant racial and ethnic differences in the management of individuals presenting with NSTEMI that were marginally attenuated by higher household income. Our findings suggest continued evidence of health inequities in contemporary NSTEMI treatment.

Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals

BACKGROUND

There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals.

METHODS

Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization.

RESULTS

Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P<0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P<0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P<0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P<0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P<0.001) and resource utilization.

CONCLUSIONS

Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry

BACKGROUND

In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure.

METHODS

This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS.

RESULTS

Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)].

CONCUSIONS

In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up.

BRIEF SUMMARY

In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study

BACKGROUND

The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.

METHODS

We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.

RESULTS

A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).

CONCLUSION

Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study

BACKGROUND

The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.

METHODS

We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.

RESULTS

A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).

CONCLUSION

Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

The Role of Place in Disparities Affecting Black Men Receiving Hemodialysis

INTRODUCTION

Black men are over-represented in the end stage kidney disease population and are at disproportionate risk of unfavorable outcomes. There is a paucity of investigation to elucidate the mediators of this risk. This study attempts to identify residential community attributes as a possible contributor.

METHODS

A post-hoc analysis of prospectively collected data from a cohort of Black men enrolled in the US Dialysis Outcomes and Practice Patterns Study (DOPPS), 2010--2015, linked to the American Community Survey, by dialysis facility zip codes was undertaken. The exposure variable was the dialysis facility community composition as defined by percent Black residents. Negative binomial regression was used to estimate incidence rate ratio (IRR) of hospitalization (first outcome) for Black men in crude and adjusted models. Similarly, Cox proportional hazards modeling was used to estimate mortality (second outcome) for Black men by type of community.

RESULTS

A total of 702 Black men receiving chronic hemodialysis were included in the study. Black men receiving hemodialysis in communities with greater proportions of Black residents had lower Charlson scores and fewer comorbidities, but a higher rate of hypertension. They had equivalent adherence to dialysis treatments, but a lower rate of arteriovenous fistula use and fewer dialysis minutes prescribed. Black men receiving dialysis in communities with a greater proportion of Black residents (per 10% increase) had higher adjusted hospitalization rates (IRR 1.09, 95% confidence interval [CI] 1.00-1.19) and mortality (hazard ratio [HR] 1.29, 95% CI 1.05-1.59).

CONCLUSIONS

This study supports the unique role of residential community as a risk factor for Black men with end stage kidney disease, showing higher hospitalization and mortality in those treating in Black versus non-Black communities, despite equivalent adherence and fewer comorbidities.

Trends, Management, and Outcomes of Acute Myocardial Infarction Hospitalizations With In-Hospital-Onset Versus Out-of-Hospital Onset: The ARIC Study

Background Acute myocardial infarction (AMI) with in-hospital onset (AMI-IHO) has poor prognosis but is clinically underappreciated. Whether its occurrence has changed over time is uncertain. Methods and Results Since 1987, the ARIC (Atherosclerosis Risk in Communities) study has conducted adjudicated surveillance of AMI hospitalizations in 4 US communities. Our analysis was limited to patients aged 35 to 74 years with symptomatic AMI. Patients with symptoms initiating after hospital arrival were considered AMI-IHO. A total of 26 678 weighted hospitalizations (14 276 unweighted hospitalizations) for symptomatic AMI were identified from 1995 to 2014, with 1137 (4%) classified as in-hospital onset. The population incidence rate of AMI-IHO increased in the 4 ARIC communities from 1995 through 2004 to 2005 through 2014 (12.7-16.9 events per 100 000 people; P for 20-year trend <0.0001), as did the proportion of AMI hospitalizations with in-hospital onset (3.7%-6.1%; P for 20-year trend =0.03). The 10-year proportions were stable for patients aged 35 to 64 years (3.0%-3.4%; P for 20-year trend =0.3) but increased for patients aged ≥65 years (4.6%-7.8%; P for 20-year trend =0.008; P for interaction by age group =0.04). AMI-IHO had a more severe clinical course with lower use of AMI therapies or invasive strategies and higher in-hospital (7% versus 3%), 28-day (19% versus 5%), and 1-year (29% versus 12%) mortality (P<0.0001 for all). Conclusions In this population-based community surveillance, AMI-IHO increased from 2005 to 2014, particularly among older patients. Quality initiatives to improve recognition and management of AMI-IHO should be especially focused on hospitalized patients aged >65.

Predictors of Mortality by Sex and Race in Heart Failure With Preserved Ejection Fraction: ARIC Community Surveillance Study

Background

Heart failure with preserved ejection fraction (HFpEF) accounts for half of heart failure hospitalizations, with limited data on predictors of mortality by sex and race. We evaluated for differences in predictors of all‐cause mortality by sex and race among hospitalized patients with HFpEF in the ARIC (Atherosclerosis Risk in Communities) Community Surveillance Study.

Methods and Results

Adjudicated HFpEF hospitalization events from 2005 to 2013 were analyzed from the ARIC Community Surveillance Study, comprising 4 US communities. Comparisons between clinical characteristics and mortality at 1 year were made by sex and race. Of 4335 adjudicated acute decompensated heart failure cases, 1892 cases (weighted n=8987) were categorized as HFpEF. Men had an increased risk of 1‐year mortality compared with women in adjusted analysis (hazard ratio [HR], 1.27; 95% CI, 1.06–1.52 [P=0.01]). Black participants had lower mortality compared with White participants in unadjusted and adjusted analyses (HR, 0.79; 95% CI, 0.64–0.97 [P=0.02]). Age, heart rate, worsening renal function, and low hemoglobin were associated with increased mortality in all subgroups. Higher body mass index was associated with improved survival in men, with borderline interaction by sex. Higher blood pressure was associated with improved survival among all groups, with significant interaction by race.

Conclusions

In a diverse HFpEF population, men had worse survival compared with women, and Black participants had improved survival compared with White participants. Age, heart rate, and worsening renal function were associated with increased mortality across all subgroups; high blood pressure was associated with decreased mortality with interaction by race. These insights into sex‐ and race‐based differences in predictors of mortality may help strategize targeted management of HFpEF.

Myocardial infarction classification and its implications on measures of cardiovascular outcomes, quality, and racial/ethnic disparities

Heart disease continues to be the leading cause of death in the United States, with approximately 805 000 cumulative deaths from myocardial infarctions (MI) from 2005 to 2014. Gender and racial/ethnic disparities in MI diagnoses are becoming more evident in quality review audits. Although recent changes in diagnostic codes provided an improved framework, clinically distinguishing types of MI remains a challenge. MI misdiagnoses and health disparities contribute to adverse outcomes in cardiac medicine. We conducted a literature review of relevant biomedical sources related to the classification of MI and disparities in cardiovascular care and outcomes. From the studies analyzed, African Americans and women have higher rates of mortality from MI, are more probably to be younger and present with other comorbidities and are less probably to receive novel therapies with respect to type of MI. As high‐sensitivity troponin assays are adopted in the United States, implementation should account for how race and sex differences have been demonstrated in the reference range and diagnostic threshold of the newer assays. More research is needed to assess how the complexity of health disparities contributes to adverse cardiovascular outcomes. Creating dedicated medical quality teams (physicians, nurses, clinical documentation improvement specialists, and medical coders) and incorporating a plan‐do‐check‐adjust quality improvement model are strategies that could potentially help better define and diagnose MI, reduce financial burdens due to MI misdiagnoses, reduce cardiovascular‐related health disparities, and ultimately improve and save lives.

Ethnic and Racial Disparities in Acute Myocardial Infarction

PURPOSE OF REVIEW

Significant racial and ethnic healthcare disparities exist in the management and outcomes of patients with acute myocardial infarction (AMI). This review will highlight the recent studies focusing on disparities in AMI care and how practice patterns have changed over time, and discuss solutions and future directions to overcome disparities in AMI care.

RECENT FINDINGS

AMI continues to be a leading cause of morbidity and mortality in the USA. Racial and ethnic disparities continue to be present in the care and outcomes associated with AMI. Non-white individuals continue to receive less guideline-concordant care and experience higher rates of adverse outcomes compared with white individuals. Health policy and quality improvement interventions have helped to narrow the gap; however, ongoing efforts are needed to continue to attempt to eliminate this disparity. Racial and ethnic disparities persist in the presentation, management, and outcomes of patients with AMI. Improvements in care have narrowed some of the inequalities. Ongoing research and efforts directed at improving access to care, eliminating bias in healthcare, and focusing on coronary heart disease prevention are needed to eliminate disparities.

Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory From the American Heart Association

The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association's vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.

Trends and predictors of coronary revascularization in patients with coronary artery anomalies and acute myocardial infarction: a nationwide analysis of 8131 patients

OBJECTIVE

Acute myocardial infarction (AMI) is rarely associated with coronary artery anomalies (CAA). This confluence makes it difficult to identify and treat the culprit lesion with percutaneous coronary intervention (PCI). Our objective was to evaluate trends and predictors of revascularization in patients with CAA and AMI using a large national database.

METHODS

We included adult patients with CAA presenting as ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) and undergoing coronary angiography from Nationwide Inpatient Sample from 2000 to 2011, using ICD-9 diagnosis code of 746.85 for CAA. Chi-square test for trend was used to compare revascularization rates over time. Multivariate logistic regression was used to identify predictors of revascularization.

RESULTS

There were almost 4.7 million subjects with AMI undergoing coronary angiography from 2000 to 2011. Of these, there were 8131 patients with CAA, including 3425 STEMI and 4706 NSTEMI patients. Mean age of the CAA population was 59 years with 63.6% males. Overall PCI rate was 47.8% and coronary artery bypass grafting rate was 8.8%. In STEMI patients with CAA, PCI rate increased from 49.9% in 2000 to 77.8% in 2011 (P < 0.001). In NSTEMI patients with CAA, PCI rate remained unchanged from 33.3% in 2000 to 37.3% in 2011 (P = 0.34). Revascularization trends in AMI patients with CAA mirrored those in AMI patients without CAA.

CONCLUSION

Despite the technical challenges associated with PCI in CAA, PCI rates in STEMI patients with CAA continue to increase over time. On the contrary, PCI rates continue to remain low in CAA patients with NSTEMI, reflecting overall contemporary NSTEMI treatment trends.

Fifteen-Year Trends in Management and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Among Black and White Patients: The ARIC Community Surveillance Study, 2000-2014

Background

Standardization of evidence‐based medical therapies has improved outcomes for patients with non–ST‐segment–elevation myocardial infarction (NSTEMI). Although racial differences in NSTEMI management have previously been reported, it is uncertain whether these differences have been ameliorated over time.

Methods and Results

The ARIC (Atherosclerosis Risk in Communities) Community Surveillance study conducts hospital surveillance of acute myocardial infarction in 4 US communities. NSTEMI was classified by physician review, using a validated algorithm. From 2000 to 2014, 17 755 weighted hospitalizations for NSTEMI (patient race: 36% black, 64% white) were sampled by ARIC. Black patients were younger (aged 60 versus 66 years), more often female (45% versus 38%), and less likely to have medical insurance (88% versus 93%) but had more comorbidities. Black patients were less often administered aspirin (85% versus 92%), other antiplatelet therapy (45% versus 60%), β‐blockers (85% versus 88%), and lipid‐lowering medications (68% versus 76%). After adjustments, black patients had a 24% lower probability of receiving nonaspirin antiplatelets (relative risk: 0.76; 95% confidence interval, 0.71–0.81), a 29% lower probability of angiography (relative risk: 0.71; 95% confidence interval, 0.67–0.76), and a 45% lower probability of revascularization (relative risk: 0.55; 95% confidence interval, 0.50–0.60). No suggestion of a changing trend over time was observed for any NSTEMI therapy (P values for interaction, all >0.20).

Conclusions

This longitudinal community surveillance of hospitalized NSTEMI patients suggests black patients have more comorbidities and less likelihood of receiving guideline‐based NSTEMI therapies, and these findings persisted across the 15‐year period. Focused efforts to reduce comorbidity burden and to more consistently implement guideline‐directed treatments in this high‐risk population are warranted.

Use of Percutaneous Coronary Intervention Among Black and White Patients With End-Stage Renal Disease in the United States

Background Racial disparities in invasive cardiac procedures such as percutaneous coronary intervention (PCI) in the general population are well documented; however, national-level data on such disparities in the end-stage renal disease (ESRD) population are lacking. We assessed racial differences in PCI between black and white patients with ESRD on maintenance dialysis. Methods and Results Using the US Renal Data System database, we abstracted Medicare inpatient procedure claims for PCI in a cohort of 268 575 Medicare-primary patients who initiated treatment on maintenance dialysis from January 1, 2009, through June 1, 2013. We conducted Cox regression analyses with PCI being the event, adjusted for demographic characteristics, Hispanic ethnicity, cause of ESRD, comorbidities, and socioeconomic factors. We also assessed the probability of PCI, accounting for death or transplant in competing risk regression models. The crude incidence rate of PCI among white patients was 25.8 per 1000 patient-years versus 15.5 per 1000 patient-years among black patients. Cox regression analyses demonstrated that black patients were significantly less likely to undergo PCI compared with white patients (adjusted hazard ratio: 0.64; 95% CI, 0.62-0.67; P<0.001). In the competing risk models, the racial gap for PCI among black and white patients remained significant with death (subdistribution hazard ratio: 0.81; 95% CI, 0.76-0.85; P<0.001) or transplant as a competing event (subdistribution hazard ratio: 0.67; 95% CI, 0.64-0.70; P<0.001). Conclusions A racial gap exists in PCI use among dialysis patients despite having comprehensive coverage with Medicare. These findings persisted despite accounting for demographic, clinical, socioeconomic factors, and death or transplant as competing events.

Impact of Sex Differences and Diabetes on Coronary Atherosclerosis and Ischemic Heart Disease

Cardiovascular diseases (CVD) including coronary artery disease (CAD) and ischemic heart disease (IHD) are the main cause of mortality in industrialized countries. Although it is well known that there is a difference in the risk of these diseases in women and men, current therapy does not consider the sexual dimorphism; i.e., differences in anatomical structures and metabolism of tissues. Here, we discuss how genetic, epigenetic, hormonal, cellular or molecular factors may explain the different CVD risk, especially in high-risk groups such as women with diabetes. We analyze whether sex may modify the effects of diabetes at risk of CAD. Finally, we discuss current diagnostic techniques in the evaluation of CAD and IHD in diabetic women.