Assessing and Addressing Social Determinants of Cardiovascular Health: JACC State-of-the-Art Review.

Social determinants of health (SDOH) are the social conditions in which people are born, live, and work. SDOH offers a more inclusive view of how environment, geographic location, neighborhoods, access to health care, nutrition, socioeconomics, and so on are critical in cardiovascular morbidity and mortality. SDOH will continue to increase in relevance and integration of patient management, thus, applying the information herein to clinical and health systems will become increasingly commonplace. This state-of-the-art review covers the 5 domains of SDOH, including economic stability, education, health care access and quality, social and community context, and neighborhood and built environment. Recognizing and addressing SDOH is an important step toward achieving equity in cardiovascular care. We discuss each SDOH within the context of cardiovascular disease, how they can be assessed by clinicians and within health care systems, and key strategies for clinicians and health care systems to address these SDOH. Summaries of these tools and key strategies are provided.

Mapping emergency department asthma visits to identify poor-quality housing in New Haven, CT, USA: a retrospective cohort study.

BACKGROUND: Housing conditions are a key driver of asthma incidence and severity. Previous studies have shown increased emergency department visits for asthma among residents living in poor-quality housing. Interventions to improve housing conditions have been shown to reduce emergency department visits for asthma, but identification and remediation of poor housing conditions is often delayed or does not occur. This study evaluates whether emergency department visits for asthma can be used to identify poor-quality housing to support proactive and early intervention. METHODS: We conducted a retrospective cohort study of children and adults living in and around New Haven, CT, USA, who were seen for asthma in an urban, tertiary emergency department between March 1, 2013, and Aug 31, 2017. We geocoded and mapped patient addresses to city parcels, and calculated a composite estimate of the incidence of emergency department use for asthma for each parcel (Nv × Np/log2[P], where Nv is the estimated mean number of visits per patient, Np is the number of patients, and P is the estimated population). To determine whether parcel-level emergency department use for asthma was associated with public housing inspection scores, we used regression analyses, adjusting for neighbourhood-level and individual-level factors contributing to emergency department use for asthma. Public housing complex inspection scores were obtained from standardised home inspections, which are conducted every 1-3 years for publicly funded housing. We used a sliding-window approach to estimate how far in advance of a failed inspection the model could identify elevated use of emergency departments for asthma, using the city-wide 90th percentile as a cutoff for elevated incidence. FINDINGS: 11 429 asthma-related emergency department visits from 6366 unique patients were included in the analysis. Mean patient age was 32·4 years (SD 12·8); 3836 (60·3%) patients were female, 2530 (39·7%) were male, 3461 (57·2%) were Medicaid-insured, and 2651 (41·6%) were Black. Incidence of emergency department use for asthma was strongly correlated with lower housing inspection scores (Pearson's r=-0·55 [95% CI -0·70 to -0·35], p=3·5 × 10-6), and this correlation persisted after adjustment for patient-level and neighbourhood-level demographics using a linear regression model (r=-0·54 [-0·69 to -0·33], p=7·1 × 10-6) and non-linear regression model (r=-0·44 [-0·62 to -0·21], p=3·8 × 10-4). Elevated asthma incidence rates were typically detected around a year before a housing complex failed a housing inspection. INTERPRETATION: Emergency department visits for asthma are an early indicator of failed housing inspections. This approach represents a novel method for the early identification of poor housing conditions and could help to reduce asthma-related morbidity and mortality. FUNDING: Harvard-National Institute of Environmental Health Sciences (NIEHS) Center for Environmental Health.

"When you're homeless, they look down on you": A qualitative, community-based study of homeless individuals with heart failure.

BACKGROUND: Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved outcomes. Homelessness poses challenges to successful SM. OBJECTIVES: To identify the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system. METHODS: We conducted open-ended, semi-structured interviews with homeless adults with HF. Data were analyzed by a multidisciplinary team using a grounded theory approach. RESULTS: We interviewed 19 participants, 11 (58%) of whom were homeless at the time of interview. Interviews revealed a combination of influences on HF SM. Major themes included instability and lack of routine, tradeoffs between basic necessities and HF SM, and stigmatization by healthcare providers. CONCLUSIONS: Anticipatory guidance aimed at the unique challenges faced by homeless individuals with HF may aid successful SM. HF providers should simlpify medication regimes and engage in non-stigmatizing discourse. Larger-scale interventions include the creation of medical respite programs.

National Trends in Emergency Department Care Processes for Acute Myocardial Infarction in the United States, 2005 to 2015.

Background Despite investments to improve quality of emergency care for patients with acute myocardial infarction (AMI), few studies have described national, real-world trends in AMI care in the emergency department (ED). We aimed to describe trends in the epidemiology and quality of AMI care in US EDs over a recent 11-year period, from 2005 to 2015. Methods and Results We conducted an observational study of ED visits for AMI using the National Hospital Ambulatory Medical Care Survey, a nationally representative probability sample of US EDs. AMI visits were classified as ST-segment-elevation myocardial infarction (STEMI) and non-STEMI. Outcomes included annual incidence of AMI, median ED length of stay, ED disposition type, and ED administration of evidence-based medications. Annual ED visits for AMI decreased from 1 493 145 in 2005 to 581 924 in 2015. Estimated yearly incidence of ED visits for STEMI decreased from 1 402 768 to 315 813. The proportion of STEMI sent for immediate, same-hospital catheterization increased from 12% to 37%. Among patients with STEMI sent directly for catheterization, median ED length of stay decreased from 62 to 37 minutes. ED administration of antithrombotic and nonaspirin antiplatelet agents rose for STEMI (23%-31% and 10%-27%, respectively). Conclusions National, real-world trends in the epidemiology of AMI in the ED parallel those of clinical registries, with decreases in AMI incidence and STEMI proportion. ED care processes for STEMI mirror evolving guidelines that favor high-intensity antiplatelet therapy, early invasive strategies, and regionalization of care.

Minimally Invasive LVAD Deactivation in a 65-Year-Old Man with Recurrent Pump Thrombosis and Left Ventricular Recovery.

Pump thrombosis is a dire sequela after left ventricular assist device (LVAD) implantation. Treatment comprises antiplatelet agents, anticoagulants, thrombolytic agents, and pump exchange. Although pump exchange is the definitive therapy, it is also the most invasive, often exposing patients to the risks of repeat sternotomy and cardiopulmonary bypass. In some cases, patients experience left ventricular recovery after LVAD implantation. The optimal strategy surrounding the management of LVADs in patients who have experienced ventricular recovery is unknown; techniques range from total system explantation to partial pump resection. Here, we describe a novel means of LVAD deactivation in a 65-year-old man with recurrent pump thrombosis, via percutaneous outflow graft closure in the cardiac catheterization laboratory. We also review the existing literature on surgical and percutaneous LVAD deactivation techniques.

Cardiohepatic Interactions: Implications for Management in Advanced Heart Failure.

Liver disease is a common sequela of heart failure and can range from mild reversible liver injury to hepatic fibrosis and, in its most severe form, cardiac cirrhosis. Hepatic fibrosis and cirrhosis due to chronic heart failure have important implications for prognosis, medication management, mechanical circulatory support, and heart transplantation. This article reviews the current understanding of liver disease in heart failure and provides a framework for approaching liver disease in the advanced heart failure population.