Health inequality and inequity in HF populations: A call to action

Health inequality and inequity in HF populations: A call to action Mary Norine Walsh, MD, MACCMedical Director, HF and Cardiac TransplantationSt Vincent Heart Center, Indianapolis INPast President, American College of Cardiology @MinnowWalsh Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center 2 Eberly, et al. Circulation: Heart Failure. 2019;12:e006214 Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center 3 Eberly, et al. Circulation: Heart Failure. 2019;12:e006214 Admission to Cardiology vs Medicine Service Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center 4Eberly, et al. Circulation: Heart Failure. 2019;12:e006214 •Despite adjustment for neighborhood disadvantage, comorbidity, dx of HFpEF, & having seen a cardiologist or PCP within the past year, black and Latinx HF pts remained significantly more likely to be admitted to GMS compared to white pts. •Admission to GMS was independently associated with higher rates of 30-day readmission•No difference in mortality by admission service after multivariable adjustment.•Evidence of differential admission decisions based on age and sex Income Inequality and Outcomes in Heart Failure 5Dewan et al. JACC: Heart FailureVolume 7, Issue 4, April 2019DOI:10.1016/j.jchf.2018.11.005 Cumulative incidence plot of(A)primary composite outcome;(B)hospitalization for HF;(C)cardiovascular death; and(D)Kaplan-Meier plot of all-cause death. 6Dewan et al. JACC: Heart FailureVolume 7, Issue 4, April 2019DOI:10.1016/j.jchf.2018.11.005 Multivariate Model of Predictors of Cardiovascular Death in HF Dewan et al. JACC: Heart FailureVolume 7, Issue 4, April 2019DOI:10.1016/j.jchf.2018.11.005 KitzmanDW et al. Am J Cardiol. 2001;87:413-419. Normal (LVEF ≥55%)Mild (LVEF 45-55%)54%)Mod/severe (LVEF <45%) 23% 10% 67% Men Women Prevalence of HFpEF in Men and WomenCardiovascular Health Study 31% 27% 42% Sex and Age Distribution in Heart Failure TrialsTrial Year No. of Pts. No. (%) of Women Average Age (yr) Captopril-Digoxin 1988 300 51(17%) 57 SOLVD (prevention) 1992 4,228 486 (11.5%) 59 SOLVD (symptomatic) 1991 2,569 594 (23%) 61 CONSENSUS – I 1987 253 75 (30%) 70 MDC 1993 383 105 (27%) 49 PROMISE 1991 1,088 235 (22%) 64 Vesnarinone 1993 477 63 (13%) 58 RADIANCE 1993 178 42 (24%) 60 DIG 1997 6,800 1,520 (22.4%) 64 Carvedilol 1996 1,094 256 (23%) 48 MERIT HF 1999 3,991 898 (22.5%) 61 CIBIS II 1999 2,467 335 (20%) 61 RALES 1999 1,663 446 (27%) 65 BEST (non-VA) 2001 1791 573 (33%) 58 Total 27,282 5,679 (21%) 62 ( Lindenfeld J, et al JACC 1997;30:1417 - 19 ) Piña, I. JACC 2003;42: 2135-2138. Adult and Pediatric Heart TransplantsNumber of Transplants by Year and Location 050010001500200025003000350040004500500055006000 19821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016 Number of transplants OtherNorth AmericaEurope 2018JHLT. 2018 Oct; 37(10): 1155-1206 Adults listed for cardiac transplantation Colvin M, et al. American Journal of Transplantation, 2019 19(S2), 323-403. Cause of death among deceased heart donors 12Colvin M, et al. American Journal of Transplantation, 2019 19(S2), 323-403. Total heart transplants by sex 13 Colvin M, et al. American Journal of Transplantation, 2019 19(S2),323-403. Patient survival among adult heart transplant recipients,2010-2012, by sex 14 Colvin M, et al. American Journal of Transplantation, 2019 19(S2),323-403. Women With Heart Failure: Unheard, Untreated, and Unstudied 16 Women With Heart Failure: Unheard, Untreated, and Unstudied -women were less likely to be treated with statins, aspirin, and indicated anticoagulants-women were less likely to have received an implantable cardioverter-defibrillator and cardiac resynchronization therapy-women were also less likely:-to have received an influenza vaccination in the 12 months before trial enrollment -been enrolled in a disease management program-or been prescribed an exercise regimen 17 In the PARADIGM-HF and ATMOSPHERE trials: Walsh MN,Jessup M,Lindenfeld J. J Amer Coll Card2019,73(1)41-43;DOI:10.1016/j.jacc.2018.10.041 Women With Heart Failure: Unheard, Untreated, and Unstudied -Patients enrolled in clinical trials do not represent the average patient with the same disease. -It is not surprising that the authors found that women and men were both well treated with HF-indicated medications, as trial enrollment stipulated such treatment. -But the continued demonstration of undertreatment of women with other pharmacological, device, and exercise therapies even in the setting of randomized trials is appalling. -Even the less frequent hospitalization of women may reflect differential treatment. -If patients in the care of experienced investigators remain undertreated and inadequately referred, the average patient faces impossible odds. 18Walsh MN,Jessup M,Lindenfeld J. J Amer Coll Card2019,73(1)41-43;DOI:10.1016/j.jacc.2018.10.041