CYP2C19 Genetic Testing for Oral P2Y12 Inhibitor Therapy: A Scientific Statement From the American Heart Association.

There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record.

Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.

BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities.

Black lives matter in the cath lab, too! A proposal for the interventional cardiology community to counteract bias and racism.

Structural racism in the United States underlies racial disparities in the criminal justice system, in the healthcare system generally, and with regards to the COVID-19 pandemic. In the year 2020, these inequities combined and magnified to such a degree that it left Black Americans and physicians caring for them questioning how much Black lives matter. Academic medical centers and the major cardiology organizations responded to a global call to end racism with bold statements and initiatives. Interventional cardiologists utilize advanced equipment to mechanically treat a wide spectrum of heart problems, yet this technology has not been applied in an equitable manner. Interventional therapies are often underutilized in Blacks, exacerbating healthcare disparities and contributing to the excess cardiovascular morbidity and mortality in these communities. Racial bias, whether intentional, unconscious, systemic, or at the individual level, plays a role in these disparities. Many in the interventional cardiology community aspire to take intentional steps to reduce the impact of bias and racism in our specialty. We discuss several proposals here and provide a "report card" for interventional programs to perform a self-assessment.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) for Out-of-Hospital Cardiac Arrest due to Pulseless Ventricular Tachycardia/Fibrillation.

BACKGROUND: Survival rates for out-of-hospital cardiac arrest are very low and neurologic recovery is poor. Innovative strategies have been developed to improve outcomes. A collaborative extracorporeal cardiopulmonary resuscitation (ECPR) program for out-of-hospital refractory pulseless ventricular tachycardia (VT) and/or ventricular fibrillation (VF) has been developed between The Ohio State University Wexner Medical Center and Columbus Division of Fire. METHODS: From August 15, 2017, to June 1, 2019, there were 86 patients that were evaluated in the field for cardiac arrest in which 42 (49%) had refractory pulseless VT and/or VF resulting from different underlying pathologies and were placed on an automated cardiopulmonary resuscitation device; from these 42 patients, 16 (38%) met final inclusion criteria for ECPR and were placed on extracorporeal membrane oxygenation (ECMO) in the cardiac catheterization laboratory (CCL). RESULTS: From the 16 patients who underwent ECPR, 4 (25%) survived to hospital discharge with cerebral perfusion category 1 or 2. Survivors tended to be younger (48.0 ± 16.7 vs. 59.3 ± 12.7 years); however, this difference was not statistically significant (p=0.28) likely due to a small number of patients. Overall, 38% of patients underwent percutaneous coronary intervention (PCI). No significant difference was found between survivors and nonsurvivors in emergency medical services dispatch to CCL arrival time, lactate in CCL, coronary artery disease severity, undergoing PCI, and pre-ECMO PaO2, pH, and hemoglobin. Recovery was seen in different underlying pathologies. CONCLUSION: ECPR for out-of-hospital refractory VT/VF cardiac arrest demonstrated encouraging outcomes. Younger patients may have a greater chance of survival, perhaps the need to be more aggressive in this subgroup of patients.

Practices and Perceptions Among Surgical Oncologists in the Perioperative Care of Obese Cancer Patients.

BACKGROUND: Obesity and cancer are two common diseases in the United States. Although there is an interaction of obesity and cancer, little is known about surgeon perceptions and practices in the care of obese cancer patients. We sought to characterize perceptions and practices of surgical oncologists regarding the perioperative care of obese patients being treated for cancer. METHODS: A cross-sectional survey was designed, pilot tested, and utilized to assess perceptions and practices of surgeons treating cancer patients. Surgical oncologists were identified using a commercially available database, and Qualtrics® was used to distribute and manage the survey. Statistical analyses were completed by using SPSS. RESULTS: Of the 1731 electronic invitations, 172 recipients initiated the survey, and 157 submitted responses (91.2%). Many surgeons (65.7%) believed that obese patients are more likely to present with more advanced cancers and were more likely than system factors to explain this delayed treatment [t(87) = 4.84; p < 0.001]. Nearly two-thirds of providers (64.5%) reported that obesity had no impact on the timing of surgery; however, one-third of respondents (34.2%) were more likely to recommend preoperative nonsurgical therapy rather than upfront surgery among obese patients. For operations of the chest/abdomen and breast/soft tissue, surgeons perceived obesity to be more related to risk of postoperative than intraoperative complications (chest/abdomen mean 4.13 vs. 3.26; breast/soft tissue 4.11 vs. 2.60; p < 0.001). CONCLUSIONS: One in three surgeons reported that patient obesity would change the timing/sequence of when resection would be offered. Many surgeons perceived that obesity was related to a wide array of intra- and postoperative adverse outcomes.

Complete "in situ" avulsion of the radial artery complicating transradial coronary rotational atherectomy.

BACKGROUND: Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage. METHODS: A 48-year-old, devout Jehovah's Witness, woman with a history of coronary artery bypass surgery presented with a non-ST-segment elevation acute myocardial infarction. Pretransfer catheterization demonstrated a heavily calcified, 90% distal left main stenosis with an occluded left internal mammary artery graft to the left anterior descending coronary artery. To minimize the risk of bleeding requiring a blood transfusion, a coronary rotational atherectomy via a TR was performed. A nonhydrophilic, 7F sheath was used to accommodate the larger rotational atherectomy burr sizes. The coronary procedure was successful, but the sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. Post procedure she developed a hematoma with motor and neurological deficits of her hand. RESULTS: Emergent surgical exploration with fasciotomy was planned. The radial artery was explored and found to be redundant and pulseless, prompting proximal evaluation and revealing complete avulsion of the radial artery at its origin. An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch and surgical ligation of the radial artery was conducted. CONCLUSION: Vascular surgeons need to be aware of potential complications related to TR which are likely to increase as this method is more widely disseminated.

Enhancing the Pipeline for a Diverse Workforce.

The lack of diversity in the physician workforce is a multifactorial problem. From elementary school through college, students from minority or socioeconomically disadvantaged backgrounds achieve despite attending underresourced schools, facing low expectations from peers and teachers, and overcoming unconscious biases among decision makers. These and other obstacles lead to significant attrition of talent by the time cohorts prepare to apply to medical school. Pipeline initiatives that inspire and prepare applicants from groups underrepresented in medicine are needed to swell the ranks of diverse individuals entering our profession.

Racial Disparities in Sports Cardiology: A Review.

Importance: Racial disparities in cardiovascular health, including sudden cardiac death (SCD), exist among both the general and athlete populations. Among competitive athletes, disparities in health outcomes potentially influenced by social determinants of health (SDOH) and structural racism remain inadequately understood. This narrative review centers on race in sports cardiology, addressing racial disparities in SCD risk, false-positive cardiac screening rates among athletes, and the prevalence of left ventricular hypertrophy, and encourages a reexamination of race-based practices in sports cardiology, such as the interpretation of screening 12-lead electrocardiogram findings. Observations: Drawing from an array of sources, including epidemiological data and broader medical literature, this narrative review discusses racial disparities in sports cardiology and calls for a paradigm shift in approach that encompasses 3 key principles: race-conscious awareness, clinical inclusivity, and research-driven refinement of clinical practice. These proposed principles call for a shift away from race-based assumptions towards individualized, health-focused care in sports cardiology. This shift would include fostering awareness of sociopolitical constructs, diversifying the medical team workforce, and conducting diverse, evidence-based research to better understand disparities and address inequities in sports cardiology care. Conclusions and Relevance: In sports cardiology, inadequate consideration of the impact of structural racism and SDOH on racial disparities in health outcomes among athletes has resulted in potential biases in current normative standards and in the clinical approach to the cardiovascular care of athletes. An evidence-based approach to successfully address disparities requires pivoting from outdated race-based practices to a race-conscious framework to better understand and improve health care outcomes for diverse athletic populations.

Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study.

Objective: To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. Methods: We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. Results: A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. Conclusion: Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.

Increasing the Representation of Black Men in Medicine by Addressing Systems Factors.

In 2015, data released by the Association of American Medical Colleges (AAMC) showed that there were more Black men applying and matriculating to medical school in 1978 than 2014. The representation of Black men in medicine is a troubling workforce issue that was identified by the National Academies of Sciences, Engineering, and Medicine as a national crisis. While premedical pathway programs have contributed to increased workforce diversity, alone they are insufficient to accelerate change. In response, the AAMC and the National Medical Association launched a new initiative in August 2020, the Action Collaborative for Black Men in Medicine, to address the systems factors that influence the trajectory to medicine for Black men. The authors provide a brief overview of the educational experiences of Black boys and men in the United States and, as members of the Action Collaborative, describe their early work. Using research, data, and collective lived experiences, the Action Collaborative members identified premedical and academic medicine systems factors that represented opportunities for change. The premedical factors include financing and funding, information access, pre-health advisors, the Medical College Admission Test, support systems, foundational academics, and alternative career paths. The academic medicine factors include early identification, medical school recruitment and admissions, and leadership accountability. The authors offer several points of intervention along the medical education continuum, starting as early as elementary school through medical school matriculation, for institutional leaders to address these factors as part of their diversity strategy. The authors also present the Action Collaborative's process for leveraging collective impact to build an equity-minded action agenda focused on Black men. They describe their initial focus on pre-health advising and leadership accountability and next steps to develop an action agenda. Collective impact and coalition building will facilitate active, broad engagement of partners across sectors to advance long-term systems change.

Enhancing the Pipeline for a Diverse Workforce.

The lack of diversity in the physician workforce is a multifactorial problem. From elementary school through college, students from minority or socioeconomically disadvantaged backgrounds achieve despite attending underresourced schools, facing low expectations from peers and teachers, and overcoming unconscious biases among decision makers. These and other obstacles lead to significant attrition of talent by the time cohorts prepare to apply to medical school. Pipeline initiatives that inspire and prepare applicants from groups underrepresented in medicine are needed to swell the ranks of diverse individuals entering our profession.

Engaging Families in Adult Cardiovascular Care: A Scientific Statement From the American Heart Association.

Family engagement empowers family members to become active partners in care delivery. Family members increasingly expect and wish to participate in care and be involved in the decision-making process. The goal of engaging families in care is to improve the care experience to achieve better outcomes for both patients and family members. There is emerging evidence that engaging family members in care improves person- and family-important outcomes. Engaging families in adult cardiovascular care involves a paradigm shift in the current organization and delivery of both acute and chronic cardiac care. Many cardiovascular health care professionals have limited awareness of the role and potential benefits of family engagement in care. Additionally, many fail to identify opportunities to engage family members. There is currently little guidance on family engagement in any aspect of cardiovascular care. The objective of this statement is to inform health care professionals and stakeholders about the importance of family engagement in cardiovascular care. This scientific statement will describe the rationale for engaging families in adult cardiovascular care, outline opportunities and challenges, highlight knowledge gaps, and provide suggestions to cardiovascular clinicians on how to integrate family members into the health care team.

Diversity in modern heart failure trials: Where are we, and where are we going.

Over the last three decades, increased attention has been given to the representation of historically underrepresented groups within the landscape of pivotal clinical trials. However, recent events (i.e., coronavirus pandemic) have laid bare the potential continuation of historic inequities in available clinical trials and studies aimed at the care of broad patient populations. Anecdotally, cardiovascular disease (CVD) has not been immune to these disparities. Within this review, we examine and discuss recent landmark CVD trials, with a specific focus on the representation of Blacks within several critically foundational heart failure clinical trials tied to contemporary treatment strategies and drug approvals. We also discuss solutions for inequities within the landscape of cardiovascular trials. Building a more diverse clinical trial workforce coupled with intentional efforts to increase clinical trial diversity will advance equity in cardiovascular care.

Disparities in Asthma and Allergy Care: What Can We Do?

The coronavirus disease pandemic and the growing movements for social and racial equality have increased awareness of disparities in American health care that exist on every level. Social determinants of health, structural racism, and implicit bias play major roles in preventing health equity. We begin with the larger picture and then focus on examples of systemic and health inequities and their solutions that have special relevance to allergy-immunology. We propose a 4-prong approach to address inequities that requires (1) racial and ethnic inclusivity in research with respect to both participants and investigators, (2) diversity in all aspects of training and practice, (3) improvement in communication between clinicians and patients, and (4) awareness of the social determinants of health. By communication we mean sensitivity to the role of language, cultural background, and health beliefs in physician-patient interactions and provision of training and equipment so that the use of telecommunication can be a resource for all patients. The social determinants of health are the social factors that affect health and the success of health care, such as adequacy of housing and access to nutritious foods. Using this 4-prong approach we can overcome health disparities.

Racism and Cardiology: A Global Call to Action.

Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty.

Le racisme et la discrimination raciale influent sur la vie et la santé cardiovasculaire des membres des minorités. Le fait que les groupes minoritaires tendent à présenter plus de facteurs de risque de maladies cardiovasculaires est souvent le résultat de politiques racistes qui restreignent les possibilités de vivre dans des quartiers sains et d'avoir accès à une éducation et à des soins de santé de grande qualité. Le fait que les minorités tendent à afficher les pires résultats lorsqu'une maladie cardiovasculaire se manifeste est souvent le résultat d'une discrimination raciale systémique ou individuelle à l'œuvre dans leurs interactions avec le système de santé. Dans le présent article, nous traitons de la discrimination et du racisme structurel du point de vue de cardiologues du Canada, du Royaume-Uni et des États-Unis. Nous abordons également l'incidence de la discrimination raciale sur les soins cardiovasculaires. Enfin, nous proposons certaines mesures visant à atténuer l'effet du racisme dans notre spécialité.

Association of Socioeconomic Status With Ideal Cardiovascular Health in Black Men.

Background Black men are burdened by high cardiovascular risk and the highest all-cause mortality rate in the United States. Socioeconomic status (SES) is associated with improved cardiovascular risk factors in majority populations, but there is a paucity of data in Black men. Methods and Results We examined the association of SES measures including educational attainment, annual income, employment status, and health insurance status with an ideal cardiovascular health (ICH) score, which included blood pressure, glucose, cholesterol, body mass index, physical activity, and smoking in African American Male Wellness Walks. Six metrics of ICH were categorized into a 3-tiered ICH score 0 to 2, 3 to 4, and 5 to 6. Multinomial logistic regression modeling was performed to examine the association of SES measures with ICH scores adjusted for age. Among 1444 men, 7% attained 5 to 6 ICH metrics. Annual income <$20 000 was associated with a 56% lower odds of attaining 3 to 4 versus 0 to 2 ICH components compared with ≥$75 000 (P=0.016). Medicare and no insurance were associated with a 39% and 35% lower odds of 3 to 4 versus 0 to 2 ICH components, respectively, compared with private insurance (all P<0.05). Education and employment status were not associated with higher attainment of ICH in Black men. Conclusions Among community-dwelling Black men, higher attainment of measures of SES showed mixed associations with greater attainment of ICH. The lack of association of higher levels of educational attainment and employment status with ICH suggests that in order to address the long-standing health inequities that affect Black men, strategies to increase attainment of cardiovascular health may need to address additional components beyond SES.

How Clinicians and Educators Can Mitigate Implicit Bias in Patient Care and Candidate Selection in Medical Education.

In an attempt to help us navigate a complex world, our unconscious minds make certain group associations on the basis of our experiences. Physicians are not immune to these implicit associations or biases, which can lead physicians to unknowingly associate certain demographic groups with negative concepts, like danger, noncompliance, and lower competence. These biases can influence clinical decision making in ways that potentially harm patients and may unfairly influence the medical school, residency, and fellowship application processes for candidates in certain underrepresented groups. To minimize the potential negative impact of implicit biases on patient care and diversity in the medical profession, physician-leaders have a responsibility to understand biases and how to consciously override them. This article discusses the potential impact of implicit bias in health care and student/trainee selection and reviews research-proven tools to reduce implicit bias in one-on-one interactions.