Disparities in heart failure between White, Black, and Hispanic young adults: insights from the National Health and Nutrition Examination Survey.

BACKGROUND: The prevalence of heart failure (HF) is increasing among young adults in the United States with pervasive racial and ethnic differences in this population. OBJECTIVE: To evaluate contemporary associations between race and ethnicity, clinical comorbidities, and outcomes among young to middle-aged adults with HF. METHODS: A retrospective analysis was performed using the National Health and Nutrition Examination Survey. All participants with a self-report of HF aged 20-64 years from 2005 to 2018 were included and stratified by race and ethnicity [non-Hispanic (NH) Whites, NH Blacks, and Hispanics]. Data on baseline characteristics including age, sex, marital status, citizenship, education level, body mass index, insurance, waist circumference, cigarette smoking, marijuana use, and relevant clinical comorbidities were included. Weighted logistic regression was performed to estimate adjusted odds ratios (aOR) to determine the association of race and ethnicity with HF. Cox proportional-hazards models were used to assess the association of race and ethnicity with all-cause and cardiac mortality. RESULTS: A total of 1,940,447 young to middle-aged adults had self-reported HF between 2005 and 2018, of whom 61% were NH White, 40% were NH Black, and 22% were Hispanic. When compared with NH White adults, NH Black adults had higher odds of HF adjusted for age, sex, insurance status, marital status, education level, citizenship status, and clinical comorbidities (adjusted aOR 2.63, 95% CI: 1.71-4.05, p < 0.001). There was no significant difference in the odds of HF between Hispanic and NH White adults (aOR 1.18, 95% CI: 0.64-2.18, p = 0.585). NH Black adults had higher mean systolic and diastolic blood pressure, and a comparable or lower burden of cardiovascular and non-cardiovascular clinical comorbidities compared with NH White and Hispanic adults. No statistical significance was noted by race and ethnicity for all-cause and cardiac mortality during a follow-up of 5 years. CONCLUSION: NH Black young to middle-aged adults were more likely to have HF which may be related to higher blood pressure given the largely similar burden of clinically relevant comorbidities compared with other racial and ethnic groups.

Racial and ethnic disparities in cardiovascular disease - analysis across major US national databases.

BACKGROUND: There are several studies that have analyzed disparities in cardiovascular disease (CVD) health using a variety of different administrative databases; however, a unified analysis of major databases does not exist. In this analysis of multiple publicly available datasets, we sought to examine racial and ethnic disparities in different aspects of CVD, CVD-related risk factors, CVD-related morbidity and mortality, and CVD trainee representation in the US. METHODS: We used National Health and Nutrition Examination Survey, National Ambulatory Medical Care Survey, National Inpatient Sample, Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research, United Network for Organ Sharing, and American Commission for Graduate Medical Education data to evaluate CVD-related disparities among Non-Hispanic (NH) White, NH Black and Hispanic populations. RESULTS: The prevalence of most CVDs and associated risk factors was higher in NH Black adults compared to NH White adults, except for dyslipidemia and ischemic heart disease (IHD). Statins were underutilized in IHD in NH Black and Hispanic patients. Hospitalizations for HF and stroke were higher among Black patients compared to White patients. All-cause, CVD, heart failure, acute myocardial infarction, IHD, diabetes mellitus, hypertension and cerebrovascular disease related mortality was highest in NH Black or African American individuals. The number of NH Black and Hispanic trainees in adult general CVD fellowship programs was disproportionately lower than NH White trainees. CONCLUSION: Racial disparities are pervasive across the spectrum of CVDs with NH Black adults at a significant disadvantage compared to NH White adults for most CVDs.

Socioeconomic status and in-hospital outcomes for patients undergoing heart transplantation or ventricular assist device implantation.

INTRODUCTION: Although lower socioeconomic status (SES) has been associated with worse in-hospital outcomes among patients with heart failure, the in-hospital outcomes for patients undergoing durable Left Ventricular Assist Device (LVAD) implantation or Heart Transplantation (HT) based on SES have not been well characterized. METHODS: We analyzed data from the National Inpatient Sample of hospitalizations between January 2016 and December 2020 of patients aged 18 and over who underwent a HT or newly implanted LVAD. Quartile classification of the median household income of the patient's residential zip code was used to estimate SES. Multivariable analyses with logistic and linear regression were used to evaluate the effects of SES on inpatient outcomes including inpatient mortality, length of stay, and key inpatient complications. RESULTS: A total of 16,265 weighted hospitalizations for new LVAD implantation and 14,320 weighted hospitalizations for HT were identified. In multivariable analysis, among patients undergoing HT or LVAD implantation respectively, there were no significant differences between the lowest and highest SES quartiles among important in-hospital outcomes including length of stay (adj B-coeff .56, (-3.59)-(4.71), p = .79 and adj B-coeff 2.40, (-.21)-(5.02), p = .07) and mortality (aOR 1.02, .61-1.70, p = .94 and aOR 1.08, .72-1.62, p = .73). There were also no differences based on SES quartile in important inpatient complications including stroke and cardiac arrest. CONCLUSION: In this analysis from the National Inpatient Sample, we demonstrate that SES, evaluated by median zip code income, was not associated with important in-hospital metrics including mortality and length of stay among patients undergoing LVAD or HT.

Improving Access to Cardiovascular Care Through Telehealth: A Single-Center Experience.

Background: Historically, access to healthcare has been a serious shortcoming of our healthcare system. Approximately 14.5% of US adults lack readily available access to health care and this has been worsened by the coronavirus disease 2019 (COVID-19) pandemic. There are limited data on the use of telehealth in cardiology. We share our single-center experience in improving access to care via telehealth at the University of Florida, Jacksonville cardiology fellows' clinic. Methods: Demographic and social variables were collected 6 months before and 6 months after the initiation of telehealth services. The effect of telehealth was determined via Chi-square and multiple logistic regression while controlling for demographic covariates. Results: We analyzed 3,316 cardiac clinic appointments over 1 year. Of these, 1,569 and 1,747 were before and after the start of telehealth, respectively. Fifteen percent (272 clinical encounters) out of the 1,747 clinic visits during the post-telehealth era were through telehealth, completed via audio or video consultation. Overall, there was a 7.2 % increase in attendance after the implementation of telehealth (P value < 0.001). Patients who attended their scheduled follow-up had significantly greater odds of being in the post-telehealth group while controlling for marital status and insurance type (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.07 - 1.62). Patients who attended had higher odds of having City-Contract insurance - an institution-specific indigenous care plan (OR: 3.51, 95% CI: 1.79 - 6.87) compared to private insurance. Patients who attended also had higher odds of being previously married (OR: 1.34, 95% CI: 1.05 - 1.70) or married/dating (OR: 1.39, 95% CI: 1.05 - 1.82) compared to patients who were single. Surprisingly, telehealth did not lead to an increase in the use of Mychart, our electronic patient portal (P value = 0.55). Conclusions: Telehealth enhanced patients' access to care by improving appointment show-rate in a cardiology fellows' clinic during the COVID-19 pandemic. Telehealth as a resource adjunct to traditional care in cardiology fellows' clinic should be further explored.

Alarming Eosinophilia From Dobutamine Infusion.

A 49-year-old male with a history of nonischemic heart failure with reduced ejection fraction, hypertension, diabetes was admitted for cardiogenic shock. Treatment started with a high dose of dobutamine infusion. While the patient's volume status improved, his clinical status declined as he became febrile and hypotensive. He was found to have severe dobutamine-induced eosinophilia, corrected only upon dobutamine cessation and steroid administration. A comprehensive investigation ruled out other potential etiologies. Peripheral eosinophilia is a rare adverse effect associated with dobutamine, leading to a significant deterioration in already decompensated patients.

Reciprocal ST-Segment Changes in Myocardial Infarction: Ischemia at Distance Versus Mirror Reflection of ST-Elevation.

BACKGROUND: Reciprocal ST-depression in the electrocardiograms (ECGs) of patients with ST-elevation myocardial infarction (STEMI) results from either true ischemia at a distance via collateral circulation diverting blood to the infarcted region or an electrical phenomenon that results from a mirror reflection of ST-elevation. We aimed to identify the role of reciprocal ECG changes in predicting collateral circulation to the infarcted area determined angiographically. METHODS: In a retrospective study, ECG and angiography of 53 STEMI patients admitted to SUNY Upstate Medical University in 2014 were reviewed independently by experts blinded to the results of ECG and coronary angiography. RESULTS: Reciprocal changes (RC) in ECG were present in 41 patients (77%) and on angiography, 14 patients (26%) exhibited collateral vessels to the ischemic areas. No correlation was found between the presence of RC and collateral circulation (P = 0.384), or between the depth of reciprocal ST-depression and the degree of the collateral circulation (P = 0.195). However, 84% of patients without collaterals exhibited resolution of RC after successful percutaneous coronary intervention (PCI) (P = 0.036), suggesting that the ST depressions that resolved after reperfusion were directly caused by the culprit vessel. Patients without RC presented late after symptom onset (9.25 versus 3.83 hours, P = 0.004), also suggesting time related resolution. CONCLUSIONS: RC had no relation to or predictive value for collaterals on angiography. Among late presenting patients, RC were less frequent. Thus, reciprocal ST-depression may represent subendocardial ischemia from the primary coronary event or simply an electrical phenomenon, rather than ischemia at distance from impaired collateral circulation.

Pathophysiologic Mechanisms in Heart Failure: Role of the Sympathetic Nervous System.

The syndrome of heart failure involves complex pathophysiologic mechanisms and is associated with extremely high-morbidity, mortality and economic costs. This growing global epidemic has diverse etiologies and is fundamentally characterized by dyshomeostasis between heart and kidneys, leading to development and progression of the cardiorenal syndrome. Excessive and sustained sympathoexcitation has emerged as a single prominent factor involved in the structural and functional dysfunction of multiple organ systems during this disease. Studies in experimental models of heart failure indicate that ablation of the renal nerves may help restore renal sodium and water equilibrium as well as the attenuation of adverse cardiac remodeling. With the recent development of minimally invasive endovascular renal denervation in humans, it is anticipated that this technology would become a novel and important paradigm shift in the management of heart failure.

Left ventricular outflow tract obstruction after bioprosthetic mitral valve replacement with preservation of the anterior leaflet.

A 79-year-old woman with a history of bioprosthetic aortic and mitral valve replacement with coronary artery bypass graft surgery presented with pulmonary edema 4 years after surgery. Transthoracic echocardiography and transesophageal echocardiography revealed an obstruction of the left ventricular outflow tract caused by the bioprosthetic mitral valve. We present this case, accompanied by a review of the literature.