Dr Clyde Yancy: Redefine Greatness Through a Quest for Health Equity in Heart Failure

As he opened the Kanu and Docey Chatterjee Keynote Address during the 72nd American College of Cardiology (ACC) Scientific Session in New Orleans on Sunday, Clyde W. Yancy, MD, MSc, the vice dean for diversity and inclusion at the Feinberg School of Medicine at Northwestern University, challenged the audience to rethink what success looks like in health care.

“This lecture gives us an opportunity to redefine what greatness means,” Yancy said. Measures of success could include whether an institution has generated a profit margin or “how efficiently you close your Epic encounters or whether you’ve met your metrics.”

But in other cultures, true greatness is defined by the world one leaves behind, as was the case with the legendary cardiologist Kanu Chatterjee, MBBS. Chatterjee, who was born in India and later became chief of cardiology at the University of California, San Francisco, was known not just for his scientific achievements, but his gentleness too. Chatterjee, who lived in a refugee camp before attending medical school, “endured significant adversity to become a physician,” Yancy said.

Chatterjee died in 2015, leaving behind the algorithms that are the foundation of today’s clinical guidelines in heart failure (HF). Yancy described Chatterjee as a “superb” bedside physician who “transmitted calm and spiritual peace to his patients.”

“I submit, you can’t do that in a 15-minute encounter,” he said.

The guidelines allow today’s treatment of HF, particularly HF with reduced ejection fraction, to be guided by evidence, not anecdote. But the guidelines do not necessarily account for challenges related to health equity—the need to reframe algorithms based on each patient’s personal circumstances, reflecting social determinants of health (SDOH). Still, the 2022 HF guidelines endorsed by the ACC, the American Heart Association, and other entities represent a genuine leap forward, Yancy said.

“I recognize quality work when I see it,” he said.

The updated guidelines emphasize several points that are essential when one thinks about health equity, “We can prevent heart failure,” Yancy said, through aggressive treatment of hypertension and other strategies.

The guidelines identify patients with stage B HF, which is asymptomatic, but can and should be treated. Yancy called on clinicians to not rely on ejection fraction alone, but the “portfolio of symptoms” of reduced ejection fraction and elevated biomarkers.

Once patients reach stages C and D, with left ventricular ejection fraction of 40% or below, Yancy emphasized the need for combination therapy; starting with a mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter 2 (SGLT2) inhibitor. These therapies, along with beta blockers and an angiotensin receptor/neprilysin inhibitor (ARNI), have been endorsed for simultaneous use, and speakers who came after Yancy discussed the underutilization of MRAs and the evidence for whether to start the 4 drugs simultaneously—including cost considerations. Physicians should gauge a patient’s response and discuss lifestyle, Yancy said.

Next, it’s important to look at key patient scenarios, including whether the patient is ambulatory, whether the patient is Black, and whether the patient has received an implantable cardioverter defibrillator. Yancy shared a slide that outlined actions to be taken in each scenario.

“This is state of the art,” Yancy said. “Let me say that again: This is state-of-the-art care for the patient with heart failure with reduced ejection fraction.” With the 2022 guidelines, the evidence can also direct physicians on how to care for patients with preserved ejection fraction.

But for the first time, “There’s another category,” he said. The guidelines, Yancy said, allow physicians to use evidence for patients with midrange ejection fraction, from 41% to 49%. “It’s a real clinical phenotype,” Yancy said, likely with a different biology, and with its own indicated therapies.

With 3 separate phenotypes, “The question becomes, if we have all these therapeutic options that can do all these different things, do we think that this actually makes the syndrome better?” Yancy asked.

He then shared work by Gregg Fonarow, MD, of UCLA, and colleagues that models use of double therapy, triple therapy, and quadruple therapy over time, going out 30 years. Yancy said this tool could help physicians talk with patients when they first have a HF diagnosis, to understand what’s now possible.

“It should be incumbent upon all of us to educate our patients—to let them know that therapies offer hope that outcomes for this condition are decidedly better,” Yancy said. “We can see that with the addition of SGLT2 inhibitors, we’re pushing out meaningful survival at least another 2 years.”

Yancy shared 2 other models: one with a more sequential approach and one introducing quadruple therapy.

“This tells us that even though we know what to do, we’re still wrestling with how to do it,” Yancy said. Medication adherence and financial toxicity are known challenges. Concepts such as a polypill have been discussed as ways to improve outcomes.

"The next question that should follow is, how do we make this happen?” he asked.

He showed another model that included the potential risk of quadruple therapy, suggesting that perhaps keeping some parts of the regimen to lower doses to avoid adverse effects is the way to go.

“We think about the parade of science introduced by Chatterjee and his contemporaries. We’ve reached the point where we can no longer accept a 50% mortality rate in 5 years. That’s all well and good, but now an even greater challenge emerges: How do we make certain that patients with heart failure are able to receive equitable care?”

Yancy said for the first time, the guidelines feature a statement that specifically states what to do “When we see patient populations not like ourselves.”

These recommendations to address disparities and vulnerable populations call for risk assessment and multidisciplinary management strategies, which should target both the known cardiovascular risk factors and SDOH to eliminate inequitable outcomes.

“And so, with the same vigor with which we apply RAS [renin-angiotensin system] inhibitors and SGLT2 inhibitors, we should understand this guideline statement,” Yancy said.

Alongside this came a second statement, which Yancy said calls for “evidence of health disparities [to] be monitored and addressed in clinical practice in the health care–system level.”

“If we are to be the whole and complete physician, if we aspire to be the great physician, these statements are necessary in our treatment algorithm,” he said.

Health systems cannot have quality initiatives that measure only whether quadruple therapy is prescribed if they make no effort to consider which patients may not be able to afford the prescriptions. Such circumstances can increase disparities, Yancy said.

“The Centers for Disease Control has explicitly defined what health equity means: It is achieved when every person could attain his or her full health potential. If you give someone a prescription for a $400 monthly pill, and they're not able to fill it, that's not equitable,”he said. “That may be equal because you prescribe the right therapy for each patient. But that's not equitable.”

Leadership, Yancy said, “is the bedrock for all of this.”

He discussed evidence about the effects of childhood exposure to stress and depression on health outcomes, as well as statements that 80% of health outcomes are driven by SDOH. The experience of HF is affected by early experiences, including trauma. Data are emerging to show the newer drug classes that treat HF behave the same way in patients from different ethnic groups, so that may not be the problem, he said.

“When we understand these varied influences, are we treating our patients equitably?”

Ethics, he said, offers a pathway to equity; just as there are 4 pillars of HF therapy, there are 4 pillars of equity: beneficence, nonmaleficence, autonomy, and justice. Yancy said these come down to: Promote the good of others. Do no harm. Promote fairness and equitable distribution of resources. And give the patient a voice.

“We must realize that equity is an ever present challenge, from my lens, from my lived experience for people that look like me. It's 100 years of history. Because my mother was born in 1950, I can speak to that 100 years of history. When she was born, there was deep, hurtful segregation. Those are the circumstances under which we seek health care.

“When I was born in 1958, right at the dawn of the civil rights era, those were very difficult times growing up,” he said. And only recently, the concept of equity “was abruptly introduced to us by the events of 2020,” he said.

“And now, we're going forward in a path that tries to see justice,” Yancy said. “Is there a moment in our history where we can remove the barriers, particularly the barriers to ideal care?”

Care today, he said, is better than it has ever been. But to achieve equity, he said, “there is still a long way to go.”