The HFSA Advanced Heart Failure and Transplant Cardiology Fellowship Consensus Conference.

There is waning interest among cardiology trainees in pursuing an Advanced Heart Failure/Transplant Cardiology (AHFTC) fellowship as evidenced by fewer applicants in the National Resident Matching Program match to this specialty. This trend has generated considerable attention across the heart failure community. In response, the Heart Failure Society of America convened the AHFTC Fellowship Task Force with a charge to develop strategies to increase the value proposition of an AHFTC fellowship. Subsequently, the HFSA sponsored the AHFTC Fellowship Consensus Conference April 26-27, 2023. Before the conference, interviews of 44 expert stakeholders diverse across geography, site of practice (traditional academic medical center or other centers), specialty/area of expertise, sex, and stage of career were conducted virtually. Based on these interviews, potential solutions to address the declining interest in AHFTC fellowship were categorized into five themes: (1) alternative training pathways, (2) regulatory and compensation, (3) educational improvements, (4) exposure and marketing for pipeline development, and (5) quality of life and mental health. These themes provided structure to the deliberations of the AHFTC Fellowship Consensus Conference. The recommendations from the Consensus Conference were subsequently presented to the HFSA Board of Directors to inform strategic plans and interventions. The HFSA Board of Directors later reviewed and approved submission of this document. The purpose of this communication is to provide the HF community with an update summarizing the processes used and concepts that emerged from the work of the HFSA AHFTC Fellowship Task Force and Consensus Conference.

Sex Differences in Heart Failure.

Heart failure (HF) continues to be a major contributor of morbidity and mortality for men and women alike, yet how the predisposition for, course and management of HF differ between men and women remains underexplored. Sex differences in traditional risk factors as well as sex-specific risk factors influence the prevalence and manifestation of HF in unique ways. The pathophysiology of HF differs between men and women and may explain sex-specific differences in clinical presentation and diagnosis. This in turn, contributes to variation in response to both pharmacologic and device/surgical therapy. This review examines sex-specific differences in HF spanning prevalence, risk factors, pathophysiology, presentation, and therapies with a specific focus on highlighting gaps in knowledge with calls to action for future research efforts.

Association Between Neighborhood-Level Poverty and Incident Atrial Fibrillation: a Retrospective Cohort Study.

BACKGROUND: Atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality. While neighborhood-level factors, such as poverty, have been related to prevalence of AF risk factors, the association between neighborhood poverty and incident AF has been limited. OBJECTIVE: Using a large cohort from a health system serving the greater Chicago area, we sought to determine the association between neighborhood-level poverty and incident AF. DESIGN: Retrospective cohort study. PARTICIPANTS: Adults, aged 30 to 80 years, without baseline cardiovascular disease from January 1, 2005, to December 31, 2018. MAIN MEASURES: We geocoded and matched residential addresses of all eligible patients to census-level poverty estimates from the American Community Survey. Neighborhood-level poverty (low, intermediate, and high) was defined as the proportion of residents in the census tract living below the federal poverty threshold. We used generalized linear mixed effects models with a logit link function to examine the association between neighborhood poverty and incident AF, adjusting for patient demographic and clinical AF risk factors. KEY RESULTS: Among 28,858 in the cohort, patients in the high poverty group were more often non-Hispanic Black or Hispanic and had higher rates of AF risk factors. Over 5 years of follow-up, 971 (3.4%) patients developed incident AF. Of these, 502 (51.7%) were in the low poverty, 327 (33.7%) in the intermediate poverty, and 142 (14.6%) in the high poverty group. The adjusted odds ratio (aOR) of AF was higher for the intermediate poverty compared with that for the low poverty group (aOR 1.23 [95% CI 1.01-1.48]). The point estimate for the aOR of AF incidence was similar, but not statistically significant, for the high poverty compared with the low poverty group (aOR 1.25 [95% CI 0.98-1.59]). CONCLUSION: In adults without baseline cardiovascular disease managed in a large, integrated health system, intermediate neighborhood poverty was significantly associated with incident AF. Understanding neighborhood-level drivers of AF disparities will help achieve equitable care.

Cardiac transplantation outcomes in patients with amyloid cardiomyopathy.

OBJECTIVE: Amyloid cardiomyopathy (ACM) is a progressive and life-threatening disease caused by abnormal protein deposits within cardiac tissue. The most common forms of ACM are caused by immunoglobulin derived light chains (AL) and transthyretin (TTR). Orthotopic heart transplantation (OHT) remains the definitive treatment for patients with end stage heart failure. In this study, we perform a contemporary multicenter analysis evaluating post OHT survival in patients with ACM. METHODS: We conducted a multicenter analysis of 40,044 adult OHT recipients captured in the United Network for Organ Sharing (UNOS) registry from 1987-2018. Patients were characterized as ACM or non-ACM. Baseline characteristics were obtained, and summary characteristics were calculated. Outcomes of interest included post-transplant survival, infection, treated rejection, and the ability to return to work. Racial differences in OHT survival were also analyzed. Unadjusted associations between ACM and non-ACM survival were determined using the Kaplan-Meier estimations and confounding was addressed using multivariable Cox proportional hazards models. RESULTS: Three hundred ninety-eight patients with a diagnosis of ACM were identified of which 313 underwent heart only OHT. ACM patients were older (61 vs 53; P < .0001) and had a higher proportion of African Americans (30.7% vs 17.6%; P < .0001). Median survival for ACM was 10.2 years vs 12.5 years in non-ACM (P = .01). After adjusting for confounding, ACM patients had a higher likelihood of death post-OHT (HR 1.39 CI: 1.14, 1.70; P = .001). African American ACM patients had a higher likelihood of survival compared to White ACM patients (HR 0.51 CI 0.31-0.85; P = .01). No difference was observed in episodes of treated rejection (OR 0.63 CI 0.23, 1.78; P = .39), hospitalizations for infections (OR 1.24 CI: 0.85, 1.81; P = .26), or likelihood of returning to work for income (OR 1.23 CI: 0.84, 1.80; P = .30). CONCLUSIONS: In this analysis of OHT in ACM, ACM was associated with a higher likelihood of post-OHT mortality. Racial differences in post-OHT were observed with African American patients with ACM having higher likelihood of survival compared to White patients with ACM. No differences were observed in episodes of treated rejection, hospitalization for infection, or likelihood to return to work for income.

Identifying and addressing social determinants of health in outpatient practice: results of a program-wide survey of internal and family medicine residents.

BACKGROUND: Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents' competence at identifying and addressing SDOH. METHODS: Residents' perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients' challenges related to SDOH through referrals. RESULTS: The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients' challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. CONCLUSIONS: Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.

The impact of operator experience during institutional adoption of trans-radial cardiac catheterization.

OBJECTIVES: We studied the impact of operator experience on trans-radial (TR) cardiac catheterization performance in contemporary practice. BACKGROUND: TR cardiac catheterization offers advantages over trans-femoral (TF) cardiac catheterization, but the TR approach has been slowly adopted in the United States. METHODS: We reviewed all cases of attempted TR cardiac catheterization at a single tertiary care medical center from May 2008 until April 2015. We classified the attending operator TR case experience at the time of each case, and the control group constituted cases performed by operators with >300 TR cases. Study endpoints were TR cannulation failure, TF cross-over, contrast medium dose, and fluoroscopy time. RESULTS: Over the study period, 4177 attempted TR cardiac catheterization cases were performed. The percentage of TR cases performed with percutaneous coronary intervention (PCI) increased from 14.0% in 2009 to 30.2% in 2015 (P-trend <0.001). The rate of TR cannulation failure decreased from 4.3% in 2009 to 2.0% in 2015 (P-trend = 0.071), and the rate of TF cross-over decreased from 4.3% in 2009 to 3.2% in 2015 (P-trend = 0.034). Operators with over 100 cases had the lowest odds of TR cannulation failure, while operators with over 200 cases had the lowest odds of TF cross-over. Operators with over 200 cases used the lowest mean contrast medium dose and mean fluoroscopy time. CONCLUSIONS: Increasing operator TR experience is associated with lower odds of TR cannulation failure and TF cross-over, as well as lower contrast medium dose and fluoroscopy time. © 2016 Wiley Periodicals, Inc.

Race, substance use, and evaluation for heart transplantation: Insights from a large urban medical center.

It is unknown whether racial disparities in access to heart transplantation (HT) are amplified when coupled with substance use. We examined patients evaluated for HT over 8 years at an urban transplant center. We evaluated substance use and race/ethnicity as independent and interactive predictors of HT and left ventricular assist device (LVAD) implantation. Of 1,148 patients evaluated for HT, substance use was cited as an ineligibility factor in 151 (13%) patients, 16 (11%) of whom ultimately received HT. Significantly more non-Hispanic Black (NHB) patients were deemed ineligible due to substance use (n = 59, 19%) compared to other races/ethnicities (non-Hispanic white: n = 68, 12%; other race/ethnicity: n = 24, p = 0.002). No racial differences were observed in the likelihood of HT among patients initially excluded for substances, but more NHB patients ultimately received LVAD than the other racial groups. This study encourages greater awareness of the role of substance use and race in the HT evaluation.