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

African Americans have worse outcomes after transcatheter and surgical aortic valve replacement: A national inpatient sample analysis from 2015 to 2020

BACKGROUND

Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are controversial among African Americans (AA). This study investigated racial disparities comparing AA and Caucasians undergoing aortic valve replacement.

METHODS

Patients who underwent SAVR and TAVR for aortic stenosis were identified in National Inpatient Sample from Q4 2015-2020. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared between AA and Caucasians using multivariable analysis, adjusting for sex, age, socioeconomic status, comorbidity, and hospital characteristics.

RESULTS

In TAVR, 51,394 (84.41 %) were Caucasians and 2433 (4.00 %) were AA. In SAVR, there were 50,080 (78.52 %) Caucasians and 3565 (5.59 %) AA. Compared to Caucasians, AA underwent TAVR had a higher risk of complications such as major adverse cardiovascular events (MACE) [adjusted odds ratio (aOR) = 1.335, p = 0.02)], respiratory complications (aOR = 1.363, p = 0.01), acute kidney injury (AKI) (aOR = 1.468, p < 0.01), pulmonary embolism (aOR = 4.65, p = 0.05), hemorrhage/hematoma (aOR = 1.202, p < 0.01), or superficial wound complication (aOR = 1.414, p = 0.04). AA who underwent SAVR had higher risks of morality (aOR = 1.184, p < 0.05) and surgical complications including MACE (aOR = 1.263, p < 0.01), pericardial complications (aOR = 1.563, p < 0.01), cardiogenic shock (aOR = 1.578, p < 0.01), respiratory complications (aOR = 1.261, p < 0.01), AKI (aOR = 1.642, p < 0.01), venous thromboembolism (aOR = 1.613, p < 0.01), hemorrhage/hematoma (aOR = 1.129, p < 0.01), infection (aOR = 1.234, p < 0.01), superficial wound complications (aOR = 1.756, p < 0.01), vascular complications (aOR = 1.592, p < 0.01), and diaphragmatic paralysis (aOR = 2.181, p = 0.02). In both TAVR and SAVR, AA had longer waiting times from admission to operation (p < 0.01), longer hospital stays (p < 0.01), and higher hospital charges (p < 0.01).

CONCLUSION

AA were underrepresented, especially in TAVR. AA experienced higher in-hospital mortality post-SAVR, but not after TAVR. Furthermore, AA had more complications for both TAVR and SAVR. These findings underscore the pronounced disparities among AA in aortic valve replacement.

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

BACKGROUND

Racial disparities in aortic valve replacement outcomes have been established. However, the current literature lacks comprehensive studies that examine the outcomes for Native Americans, probably due to their limited population size. This study aimed to investigate whether disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) also exist for outcomes among Native Americans.

METHODS

Patients who underwent SAVR and TAVR were identified in National Inpatient Sample from the last quarter of 2015 to 2020. A 1:5 propensity score matching was conducted between Native Americans and Caucasians. In-hospital perioperative outcomes, length of stay, wait from admission to operation, and total hospital charge, were compared.

RESULTS

In TAVR, 51,394 (84.41 %) were Caucasians and 171 (0.28 %) were Native Americans. In SAVR, there were 50,080 (78.52 %) Caucasians and 279 (0.44 %) Native Americans. After propensity matching, no significant difference was found in post-TAVR outcomes between Native Americans and Caucasians. However, Native Americans have a higher risk of neurological complications (2.88 % vs 0.79 %, p < 0.01) with stroke being the primary contributor (2.52 % vs 0.5 %, p < 0.01), as well as a higher incidence of venous thromboembolism (1.8 % vs 0.57 %, p < 0.05) after SAVR.

CONCLUSIONS

This study is the first to examine aortic valve replacement outcomes in Native Americans. Native Americans were found to be more likely to undergo SAVR than TAVR. Moreover, Native Americans were found to have five times higher stroke and three times higher VTE after SAVR. These disparities faced by Native Americans underscore the need for increased attention and targeted actions to guarantee health equity.

Disparity among Asian Americans in transcatheter and surgical aortic valve replacement

BACKGROUND

Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) outcomes have been established, but research has predominantly focused on African Americans and Hispanics, leaving a gap in Asian Americans. This study aimed to investigate disparities in aortic valve replacement outcomes among Asian Americans.

METHODS

Patients who underwent SAVR and TAVR were identified in National Inpatient Sample from the last quarter of 2015-2020. A 1:2 propensity score matching was applied to Asian Americans and Caucasians. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared.

RESULTS

In TAVR, 51,394 (84.41 %) were Caucasians and 795 (1.31 %) were Asian Americans. In SAVR, there were 50,080 (78.52 %) Caucasians and 1233 (1.93 %) Asian Americans. No significant difference was found in post-TAVR complications. However, Asian Americans experienced longer waiting time until operation (p = 0.03) and higher costs (p < 0.01) in TAVR. In SAVR, Asian Americans had higher risks of in-hospital mortality (3.91 % vs 2.39 %, p = 0.01), cardiogenic shock (8.71 % vs 6.74 %, p = 0.03), respiratory complications (14.08 % vs 11.2 %, p = 0.01), mechanical ventilation (13.83 % vs 9.09 %, p < 0.01), acute kidney injury (25.47 % vs 20.13 %, p < 0.01), and hemorrhage/hematoma (72.01 % vs 62.95 %, p < 0.01). Additionally, Asian Americans underwent SAVR had longer lengths of stay (p < 0.01) and higher costs (p < 0.01).

CONCLUSIONS

Asian Americans were underrepresented in aortic valve replacement. Asian Americans, while having similar post-TAVR outcomes to Caucasians, faced greater risks of post-SAVR mortality and surgical complications. These disparities among Asian Americans call for targeted actions to ensure equitable health outcomes.

Racial disparities in thoracic aortic surgery: Myth or reality?

OBJECTIVE

We examined the relationship between Black or White race and adverse outcomes in patients who underwent surgery of the ascending aorta, aortic root, or aortic arch at our center.

METHODS

We analyzed 2335 consecutive patients who identified as Black (n = 217, 9.3%) or White (n = 2118, 90.7%) and underwent proximal aortic surgery. Patient zip codes were used to determine community socioeconomic (CSE) characteristics. The composite adverse outcome comprised mortality, persistent neurologic injury, and renal failure necessitating dialysis at discharge. We performed multivariable analysis, Kaplan-Meier analysis, and propensity score matching adjusted for CSE factors.

RESULTS

Median follow-up time was 3.7 years. Compared with White patients, Black patients lived in areas characterized by a higher percentage living below poverty level, lower income, and lower education level (P < .0001). Black patients had higher rates of emergency presentation (P < .0001) and lower 5- and 10-year survival rates (P = .0002). Short-term outcomes were similar between groups, except for respiratory failure and length of stay (P < .0001), which were higher in the Black population. After propensity score matching adjusted for CSE factors, Black and White patients (n = 204 each) had similar short-term outcomes and 5- and 10-year survival rates (P = .30). Multivariable analysis stratified by race showed that CSE factors independently predicted adverse outcomes in Black but not White patients.

CONCLUSIONS

This is among few studies that have analyzed the relationship between race and proximal aortic surgery. Although outcomes were similar between Black and White patients in our cohort after adjusting for CSE factors, unfavorable CSE factors predicted adverse outcomes in Black but not White patients. More patient-specific studies are needed.

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.

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.

Exploring experiences associated with aortic stenosis diagnosis, treatment and life impact among middle-aged and older adults

BACKGROUND AND PURPOSE

Although multiple studies have examined the clinical aspects of diagnosis, treatment, and management of patients with aortic stenosis (AS), limited data exist regarding patient experiences related to symptoms, diagnosis, treatment, and personal impacts of living with AS.

METHODOLOGY

Adults aged ≥40 years diagnosed with AS were recruited and separated into three cohorts: medically managed, surgical aortic valve replacement (SAVR), and transcatheter aortic valve implantation (TAVI). Forty-five semi-structured interviews were conducted (15 per treatment group) via teleconference using open-ended questions and probes. Interview recordings were transcribed, and inductive thematic analyses were conducted.

RESULTS

The majority of participants were male (55.6%), White (95.6%), and non-Hispanic (93.3%). Participants noting longer times to diagnosis also reported mild symptom onset and experiences of misdiagnoses. Participants described a strong reliance on their health care professionals (HCPs) to guide them through their treatment decisions, which were influenced by the effects of anticoagulation, future valve interventions, and recovery. Medically managed participants reported having to make lifestyle modifications to manage symptoms, while participants who underwent TAVI or SAVR reported positive sentiments in their ability to return to normal life following their treatment.

CONCLUSIONS AND IMPLICATIONS

Due to the varied experiences of AS patients, there is a need to improve patient resources to advance patient understanding and facilitate informed treatment decisions. Reported experiences also indicate a need for additional HCP education on early referral to a multidisciplinary heart valve team.

Temporal trends in transcatheter aortic valve replacement use and outcomes by race, ethnicity, and sex

Objectives

To identify trends in transcatheter aortic valve replacement (TAVR) use and outcomes by race (non‐Hispanic White, Black), ethnicity (Hispanic), and sex over time.

Background

Despite rapid growth in TAVR use over time, our understanding of its use and outcomes among males and females of underrepresented racial/ethnic groups remains limited.

Methods

A retrospective analysis of hospitalizations from 2013 to 2017 from the Healthcare Cost and Utilization Project database was performed.

Results

White patients comprised 65% (n = 2.16 × 10⁷) of all hospitalizations, yet they comprised 83% (n = 176,887) of the admissions for aortic stenosis (p < 0.0001). Among 91,693 hospitalizations for aortic valve replacement, 64,069 were surgical (34.0% female, 7.0% Hispanic, and 5.9% Black) and 27,624 were transcatheter (46.6% female, 4.5% Hispanic, and 4.4% Black). Growth in TAVR volumes was the slowest among minorities and females. Hispanic males, Hispanic females, and White females had the highest in‐hospital mortality (2.7%–3.3%; compared to White males, adjusted odds ratio: Hispanic males 1.9 [1.2–3.0], Hispanic females 1.9 [1.2–3.1], and White females 1.4 [1.2–1.7]). Despite less baseline vascular disease, females of all races/ethnicities had more vascular complications than men (female 5% vs. male 3.5%, p ≤ 0.001). Further adjustment for vascular complications only partially attenuated mortality differences. Black and Hispanic patients had a longer mean length of hospital stay than White patients, which was most pronounced among females. Pacemaker requirements were consistently low among all groups.

Conclusion

Differences in TAVR growth and outcomes by race, ethnicity, and sex over time highlight areas for focused efforts to close gaps in minimally invasive structural heart disease care.