Black Patients’ Uptake of Advanced HF Treatments Falls Behind That of White Patients

In a new study that investigated potential racial disparities in access to advanced heart failure (HF) treatments, investigators found less use of both ventricular assist device (VAD) and heart transplant among Black patients compared with White patients, and they posited this may be due to “structural racism and discrimination or provider bias impacting decision-making.”

Their findings were published online recently in Circulation: Heart Failure from their study—a subanalysis of data from the REVIVAL trial (Registry Evaluation of Vital Information for VADs in Ambulatory Life)—that also sought to determine if patient preference while undergoing care at VAD centers from advanced HF cardiologists influenced uptake of advanced HF treatments.

Their investigation also accounted for HF severity, patient-reported quality of life (QOL), preference for VAD, desire for therapies, and social determinants of health (SDOH). Among the 377 study participants, most were White (73.5%) and male (75%), and all patients had study visits at enrollment and 2, 6, 12, 18, and 24 months or death, heart transplant, or VAD. Their mean (SD) age was 60.3 (11.3) years. The Interagency Registry for Mechanically Assisted Circulatory Support Profiles (INTERMACS) was used to gauge HF severity and the EuroQol visual analog scale (EQ-VAS) assessed patient QOL.

Fewer Black study participants vs White patients underwent a VAD implantation or a heart transplant: 11% (n = 11) vs 22.3% (n = 62). Breaking these totals down, among the Black patients, 8% received a VAD and 3% a transplant, and among the White patients, 15.5% received a VAD and 6.9% a transplant.

Overall mortality rate was still higher among Black patients for this study, 18% vs 13%, despite them having lower rates of New York Heart Association class III or IV disease vs White patients: 66% vs 69% and 1% vs 3%, respectively.

There was also a 55% reduced rate of Black patients’ utilization of VAD therapy or a heart transplant (adjusted HR, 0.45; 95% CI, 0.23-0.85)—but no concurrent increase in risk of death. Prior studies have shown Black adults have a greater risk for HF and are twice as likely to die from it, according to a press release on these study results. HF is also 20 times more likely among Black adults before age 50 and hospitalization twice as likely, note the present study authors.

Patients who had a worse INTERMACS profile, lower EQ-VAS, and a higher level of education were more likely to have undergone a heart transplant or receive a VAD. No relationship was found with care preference on treatment receipt. In addition, a worse INTERMACS profile was associated with a 95% greater risk of death (HR, 1.95; 95% CI, 1.58-2.39).

Multivariate adjustment produced a similar mortality rate between the Black and White study participants (HR, 1.23; 95% CI, 0.67-2.25), and having a higher body mass index and caregiver present were shown to be protective, at 6% (HR, 0.938; 95% CI, 0.898-0.985) and 59% (HR, 0.41; 95% CI, 0.22-0.76) reduced risk of death.

“Collectively, these findings suggest that racial inequity in VAD and transplant exists despite access to care at VAD centers by experienced providers (ie, advanced HF/transplant cardiologists),” the study authors wrote, “and that this inequity is not the result of differences in patient-expressed preference for care.”

They added that their results are an important addition to the literature because they show ongoing care disparities despite Black patients’ preference for life-sustaining therapies, including VADs. Potential contributing factor to this could be provider biases and less use of VAD because patients were not “ideal candidates,” the investigators added.

Policies are needed to identify and address these inequities, the authors emphasized, and they should include tracking health inequities “across the spectrum of SDOH.”

“The totality of the evidence suggests that we as heart failure providers are perpetuating current inequities,” said Thomas M. Cascino, MD, the first study author and a clinical instructor in the Division of Cardiovascular Disease at the University of Michigan at Ann Arbor, in a statement. “However, recognizing disparities isn’t enough. As physicians and health care providers, we must find ways to create equitable change.”

Reference

Cascino TM, Colvin MM, Lanfear DE, et al. Racial inequities in access to ventricular assist device and transplant persist after consideration for preferences for care: a report from the REVIVAL study. Circ Heart Fail. Published online October 19, 2022. doi:10.1161/CIRCHEARTFAILURE.122.009745