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Background Heart Failure (HF) is an important and growing public health problem in women. Risk factors for incident hospitalized HF with preserved (HFpEF) compared to reduced ejection fraction (HFrEF) in women, and differences by race/ethnicity, are not well characterized. Methods and Results We prospectively evaluated the risk factors for incident hospitalized HFpEF and HFrEF in a multi-racial cohort of 42,170 post-menopausal women followed for a mean of 13.2 years. Cox regression models with time dependent covariate adjustment were used to define risk factors for HFpEF and HFrEF. Differences by race/ethnicity regarding incidence rates, baseline risk factors and their population attributable risk percentage (PAR%) were analyzed. Risk factors for both HFpEF and HFrEF were as follows: older age, Caucasian race, diabetes, cigarette smoking, and hypertension. Obesity, history of coronary heart disease (other than myocardial infarction (MI)), anemia, atrial fibrillation and more than one co-morbidity, were associated with HFpEF but not HFrEF. History of MI was associated with HFrEF but not HFpEF. Obesity was found to be a more potent risk factor for African American women compared with Caucasian women for HFpEF (p for interaction= 0.007). For HFpEF, the PAR% was greatest for hypertension (40.9%) followed by obesity (25.8%), with the highest PAR% found in African Americans for these risk factors. Conclusions In this multi-racial cohort of postmenopausal women, obesity stands out as a significant risk factor for HFpEF, with the strongest association in African American women. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

BackgroundRace influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies.Methods and ResultsMembers of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation.ConclusionsBlack race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

Background: Cardiovascular disease (CVD) is the leading cause of death among American Indians and Alaska Natives. Over the past 50 years, the prevalence of CVD has been rising among American Indians and Alaska Natives. The objective of this statement is to summarize population-level risk factors and management techniques tailored for the American Indian and Alaska Native populations. Methods: PubMed/MEDLINE, the Centers for Disease Control and Prevention, and the annual Heart Disease and Stroke Statistics report from the American Heart Association were used to identify risk factors and interventions specific to American Indians and Alaska Natives. Results: Diabetes mellitus is a major contributor to disproportionately higher rates of coronary heart disease among American Indians and Alaska Natives compared with other racial and ethnic groups. Additional risk factors for CVD include low-density lipoprotein cholesterol levels, hypertension, renal disease, age, and sex. Smoking and exposure to toxic metals are risk factors for some subpopulations. A quarter of American Indians live below the federal poverty line, and thus, low socioeconomic status is an important social determinant of cardiovascular health. Community-based interventions have reduced CVD risk in American Indians and Alaska Natives. Underreporting of American Indian and Alaska Native race could underestimate the extent of CVD in this population. Conclusions: Prevention and treatment of CVD in American Indians and Alaska Natives should focus on control of risk factors and community-based interventions that address social determinants of health, particularly among individuals with diabetes mellitus. Accurate reporting of race/ethnicity is encouraged to address race-specific risk factors.

IMPORTANCE Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. OBJECTIVE To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. EXPOSURE Randomization to clinical vignettes. MAIN OUTCOMES AND MEASURES Thematic differences in allocation of advanced therapies by patient race and gender. RESULTS Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. (continued) Key Points Question Is bias against a patient's gender and race associated with the allocation of advanced heart failure therapies? Findings In a qualitative study of 46 health care professionals, there was more bias against women compared with men when evaluating appearance and social support, particularly among African American women. Fina...

Objectives The aim of this study was to determine if the Affordable Care Act (ACA) Medicaid Expansion was associated with increased census-adjusted heart transplant listing rates for racial/ethnic minorities. Background Underinsurance limits access to transplants, especially among racial/ethnic minorities. Changes in racial/ethnic listing rates post the ACA Medicaid Expansion are unknown. Methods Using the Scientific Registry of Transplant Recipients, we analyzed 5,651 patients from early adopter states (implemented ACA Medicaid Expansion by 1/2014) and 4,769 patients from non-adopter states (no implementation during study period) from 2012–2015. Piecewise linear models, stratified by race/ethnicity, were fit to monthly census-adjusted rates of heart transplant listings before and after 1/2014. Results A significant 30% increase in the rate of heart transplant listings for African-Americans in early adopter states occurred immediately following the ACA Medicaid Expansion on 1/1/2014 [pre 0.15 to post 0.20/100,000, increase 0.05/100,000 (95%Confidence Interval (CI): 0.01,0.08)]; in contrast, the rates for African-Americans in non-adopter states remained constant [pre and post 0.15/100,000, increase 0.006/100,000 (95%CI: −0.03,0.04)]. Hispanics experienced an opposite trend, with no significant change in early adopter states [pre 0.03 to post 0.04/100,000, increase 0.01/100,000 (95%CI: −0.004,0.02)] and a significant increase in non-adopter states [pre 0.03 to post 0.05/100,000, increase 0.02/100,000 (95%CI: 0.002,0.03)]. There were no significant changes in listing rates among Caucasians in either early adopter or non-adopter states. Conclusions Implementation of the ACA Medicaid Expansion was associated with increased heart transplant listings in African-Americans but not Hispanics or Caucasians. Broadening of the ACA in states with large African-American populations may reduce disparities in heart transplant listings.

Background Left ventricular remodeling, as commonly measured by left ventricular ejection fraction (LVEF), is associated with clinical outcomes. Although change in LVEF over time should reflect response to therapy and clinical course, serial measurement of LVEF is inconsistently performed in observational settings, and the incremental prognostic value of change in LVEF has not been well characterized. Methods and Results The Beta-Blocker Evaluation of Survival Trial (BEST) measured LVEF by radionuclide ventriculography at baseline and at 3 and 12-months after randomization. We built a series of multivariable models with 16 clinical parameters plus change in LVEF for predicting four major clinical endpoints including the trial’s primary endpoint of all-cause mortality (ACM). Among 2,484 patients with at least one follow-up LVEF, change in LVEF was the second most significant predictor (behind baseline creatinine) of ACM [adjusted hazards ratio for improvement in LVEF by ≥5 units (Responder) versus Non-responder (95% confidence intervals) for ACM = 0.62 (0.52–0.73)]. Other endpoints including heart failure (HF) hospitalization or the composite of ACM and HF hospitalization yielded similar results. LVEF change ≥5 units was associated with a modest increase in discrimination when added to traditional predictors, and was predictive of outcomes in both the bucindolol and placebo treatment groups. LVEF change as a predictor of outcomes was affected by sex and race, with evidence that LVEF improvement is associated with less survival benefit in African-Americans and women. Conclusions Serial evaluation for LVEF change predicts both survival and HF hospitalization and provides a dynamic/real-time measure of prognosis in HF with reduced LVEF. Clinical Trial Registration http://www.clinicaltrials.gov. Unique identifier: NCT00000560.

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