Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

Multidrug-resistant Salmonella spp. in fecal samples of pigs with suspected salmonellosis in Antioquia, Colombia, 2019-2021

Objectives

To determine the proportion of Salmonella enterica in fecal samples of live pigs with suspected salmonellosis analyzed at the diagnostic unit of the University of Antioquia, Colombia between 2019 and 2021, and examine the serotypes and antimicrobial resistance patterns.

Methods

This was a laboratory-based cross-sectional study of routine data on fecal samples received from pig farms in all nine subregions of Antioquia state, Colombia. Salmonella spp. detection at the university is done using enrichment, selective culture, and polymerase chain reaction. Serotypes were identified using the Kauffmann-White scheme and isolates were tested for antimicrobial susceptibility using broth microdilution.

Results

Of 653 samples tested, 149 (23%) were positive for S. enterica. Nine serotypes were identified. The most common were Salmonella Typhimurium (56%) and its monophasic variant (35%). Resistance to ampicillin (70%) was most frequently observed, followed by ciprofloxacin (55%), and sulfamethoxazole-trimethoprim (52%). No isolates were resistant to amikacin and gentamicin. Multidrug resistance (resistance to ≥ 3 classes of antibiotics) was observed in 61 (44%) isolates. Multidrug resistance was highest in S. Typhimurium (57%) compared with the other serotypes. Serotype was associated with multidrug resistance (p = 0.01), but age of the pig and sub-region were not.

Conclusions

The proportion of Salmonella spp. and the associated high levels of multidrug resistance are of concern and may indicate irrational use of antimicrobials and poor management practices in pig production systems in the region. Strengthened surveillance is needed to monitor and improve farm management practices and the use of antimicrobials in farms in Colombia.

Spontaneous Left Atrial Thrombus Formation on the Catheter Delivery System During WATCHMAN Implantation

We present a rare complication of spontaneous thrombus formation on the WATCHMAN delivery system, on both the right- and left-sided systemic circulation. We also describe the multidisciplinary team approach and the use of percutaneous vacuum-assisted aspiration system (AngioVac, AngioDynamics, Latham, New York) for successful thrombus removal. (Level of Difficulty: Intermediate.).

Bartonella quintana Endocarditis in a Homeless Man with Cat Exposure in San Diego, California

We report a case of Bartonella quintana endocarditis in a homeless man with congenital bicuspid aortic valve and significant cat exposure living in downtown San Diego, California.

Acute glucoregulatory and vascular outcomes of three strategies for interrupting prolonged sitting time in postmenopausal women: A pilot, laboratory-based, randomized, controlled, 4-condition, 4-period crossover trial

Background

Prolonged sitting is associated with cardiometabolic and vascular disease. Despite emerging evidence regarding the acute health benefits of interrupting prolonged sitting time, the effectiveness of different modalities in older adults (who sit the most) is unclear.

Methods

In preparation for a future randomized controlled trial, we enrolled 10 sedentary, overweight or obese, postmenopausal women (mean age 66 years ±9; mean body mass index 30.6 kg/m² ±4.2) in a 4-condition, 4-period crossover feasibility pilot study in San Diego to test 3 different sitting interruption modalities designed to improve glucoregulatory and vascular outcomes compared to a prolonged sitting control condition. The interruption modalities included: a) 2 minutes standing every 20 minutes; b) 2 minutes walking every hour; and c) 10 minutes standing every hour. During each 5-hr condition, participants consumed two identical, standardized meals. Blood samples, blood pressure, and heart rate were collected every 30 minutes. Endothelial function of the superficial femoral artery was measured at baseline and end of each 5-hr condition using flow-mediated dilation (FMD). Participants completed each condition on separate days, in randomized order. This feasibility pilot study was not powered to detect statistically significant differences in the various outcomes, however, analytic methods (mixed models) were used to test statistical significance within the small sample size.

Results

Nine participants completed all 4 study visits, one participant completed 3 study visits and then was lost to follow up. Net incremental area under the curve (iAUC) values for postprandial plasma glucose and insulin during the 5-hr sitting interruption conditions were not significantly different compared to the control condition. Exploratory analyses revealed that the 2-minute standing every 20 minutes and the 2-minute walking every hour conditions were associated with a significantly lower glycemic response to the second meal compared to the first meal (i.e., condition-matched 2-hour post-lunch glucose iAUC was lower than 2-hour post-breakfast glucose iAUC) that withstood Bonferroni correction (p = 0.0024 and p = 0.0084, respectively). Using allometrically scaled data, the 10-minute standing every hour condition resulted in an improved FMD response, which was significantly greater than the control condition after Bonferroni correction (p = 0.0033).

Conclusion

This study suggests that brief interruptions in prolonged sitting time have modality-specific glucoregulatory and vascular benefits and are feasible in an older adult population. Larger laboratory and real-world intervention studies of pragmatic and effective methods to change sitting habits are needed.

Trial registration

ClinicalTrials.gov NCT02743286.

Detection of concentric left ventricular wall hypertrophy by contrast-enhanced non-electrocardiogram-gated chest computed tomography

BACKGROUND

No established measure of concentric left ventricular wall hypertrophy (cLVH) on routine computed tomography (CT) of the adult chest currently exists. The objective of this study was to identify and test linear measures for the detection of cLVH using transthoracic echocardiography (TTE) as the reference standard.

METHODS

Contrast-enhanced non-electrocardiogram-gated chest CTs acquired within two weeks of TTE were retrospectively evaluated. Two radiologists independently made trans-axial measurements in the proximal half of the left ventricle at its approximate widest internal diameter: maximum septal thickness (sept), maximum lateral wall thickness (lat), and inner (I_d) and outer (O_d) wall-wall diameters at the level of greatest combined myocardial thickness. The sum of sept and lat, hereafter Th_max, and modified cross-sectional area (A_mod = O_d² - I_d²) were calculated. Sept, lat, Th_max, and A_mod were evaluated by receiver operating characteristic (ROC) curves using TTE as the reference standard. Thresholds were optimized for specificity and applied to a validation cohort. Inter-rater agreement was assessed by a simple unweighted Kappa statistic (κ).

RESULTS

Sept and A_mod were selected based on areas under the ROC curves of 0.75 and 0.71, respectively, using 100 CTs. Thresholds of 1.6 cm and 30 cm², respectively, showed similar specificities of 98% with sensitivities of 27% and 30%, respectively. Applied to a validation cohort of 100 CTs, sept had higher combined positive predictive value (75%), inter-rater agreement (κ = 0.58), specificity (91%), and sensitivity (24%).

CONCLUSION

Linear measures demonstrate utility in the diagnosis of cLVH on routine contrast-enhanced chest CT.

Relation of race, ethnicity and cardiac surgeons to operative mortality rates in primary coronary artery bypass grafting in California

The aim of this study was to evaluate whether African American, Hispanic, and Asian patients in California were more likely to undergo coronary artery bypass grafting (CABG) by cardiac surgeons with higher risk-adjusted mortality rates (RAMRs). Clinical data from the California CABG Outcomes Reporting Program were analyzed for all patients who underwent isolated CABG from 2003 to 2006 by surgeons who performed ≥ 10 operations. Surgeons were divided into quintiles on the basis of their RAMRs, with the top-performing surgeons in the first quintile and the lowest performing surgeons in the fifth quintile. There were 72,845 isolated CABG procedures performed by 303 surgeons, including 49,886 in white, 9,380 in Hispanic, 6,867 in Asian, and 2,750 in African American patients. African American and Asian patients underwent CABG by surgeons with higher mean RAMRs (2.90% and 2.99%, respectively) compared with the state average of 2.65% (p <0.001). Compared to white patients, Asian and Hispanic patients were more likely to be treated by surgeons in the lowest quintile (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.11 to 1.3, and OR 1.38, 95% CI 1.30 to 1.48, respectively). African Americans and Hispanics were less likely to be operated on by surgeons in the top quintile compared to white patients (OR 0.80, 95% CI 0.71 to 0.90, and OR 0.81, 95% CI 0.76 to 0.87, respectively). Hispanics were less likely to be treated by surgeons in the top quintile than by surgeons in the lowest quintile (OR 0.65, 95% CI 0.60 to 0.75). In conclusion, racial and ethnic minority patients who undergo isolated CABG in California may be more likely to be operated on by cardiac surgeons with higher RAMRs.

Racial and ethnic disparities in access to higher and lower quality cardiac surgeons for coronary artery bypass grafting

To determine whether Hispanic and African-American patients are treated by cardiac surgeons with better or worse risk-standardized outcomes than surgeons of white patients, clinical data from the Massachusetts Data Analysis Center Registry were analyzed on all patients who underwent isolated coronary artery bypass grafting (CABG) from 2002 to 2004 by surgeons who performed >or=10 operations. Surgeons were divided into 4 groups based on their risk-standardized 30-day all-cause mortality incidence rates (top decile, top quartile, bottom quartile, and bottom decile). A total of 12,973 isolated CABGs were performed by 56 surgeons for 11,800 whites (91%), 413 Hispanics (3.2%), and 251 African-Americans (1.9%). White patients were more likely to be treated by surgeons in the top decile than by surgeons in the bottom decile (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07 to 1.76). In contrast, Hispanic patients were almost 3 times more likely to be treated by surgeons in the bottom decile compared with the top decile (OR 2.85, 95% CI 1.82 to 4.47). Compared with whites, Hispanic patients were about 1/2 as less likely to be treated by surgeons in the top decile (OR 0.51, 95% CI 0.35 to 0.75). African-American and white patients were similarly likely to be treated by surgeons in the top- and bottom-quality performance groups. In conclusion, Hispanics undergoing isolated CABG in Massachusetts were more likely to be operated on by cardiac surgeons with higher risk-standardized mortality rates than by surgeons with lower rates.

Time trends in warfarin-associated hemorrhage

The annual incidence of warfarin-related bleeding at Brigham and Women's Hospital increased from 0.97/1,000 patient admissions in the first time period (January 1995 to October 1998) to 1.19/1,000 patient admissions in the second time period (November 1998 to August 2002) of this study. The proportion of patients with major and intracranial bleeding increased from 20.2% and 1.9%, respectively, in the first time period, to 33.3% and 7.8%, respectively, in the second.