Unequitable Heart Failure Therapy for Black, Hispanic and American-Indian Patients

Abstract

Despite the high prevalence of heart failure among Black and Hispanic populations, patients of colour are frequently under-prescribed guideline-directed medical therapy (GDMT) and American-Indian populations are not well characterised. Clinical inertia, financial toxicity, underrepresentation in trials, non-trustworthy medical systems, bias and structural racism are contributing factors. There is an urgent need to develop evidence-based strategies to increase the uptake of GDMT for heart failure in patients of colour. Postulated strategies include prescribing all GDMT upon first encounter, aggressive outpatient uptitration of GDMT, intervening upon social determinants of health, addressing bias and racism through changing processes or policies that unfairly disadvantage patients of colour, engagement of stakeholders and implementation of national quality improvement programmes.

Heart Failure with Reduced Ejection Fraction and COVID-19, when the Sick Get Sicker

“…62 Factors such as clinical inertia, cost of care, lack of insurance or underinsurance, clinician bias and structural racism disproportionately limit access to care for minoritized patients and can worsen during a pandemic. 13 , 35 Low prescribing patterns of HF GDMT exist overall but under prescription of HF GDMT therapy is worse in Black patients who have a higher HF disease burden than other populations. 13 , 63 , 64 For multiple centers, telemedicine did not facilitate major changes in GDMT prescribing patterns during the pandemic and in some cases resulted in lower prescribing of GDMT.…”

“… 13 , 35 Low prescribing patterns of HF GDMT exist overall but under prescription of HF GDMT therapy is worse in Black patients who have a higher HF disease burden than other populations. 13 , 63 , 64 For multiple centers, telemedicine did not facilitate major changes in GDMT prescribing patterns during the pandemic and in some cases resulted in lower prescribing of GDMT. 65 , 66 While this is variable across centers, it is important to recognized that telemedicine may not benefit under resourced communities substantially if barriers to broadband internet are not also addressed 67 , which disproportionately impacts minoritized racial and ethnic groups.…”

“… 7 , 11 , 12 In addition, minoritized racial and ethnic groups are less likely to be prescribed guideline-directed medical therapy (GDMT) and nonpharmacological therapies. 5 , 13 …”

Do outcomes for heart transplantation differ based on donor and recipient race?

“…When compared to other ethnic groups, this group has the highest rates of heart failure and greatest mortality. [1][2][3][4][5][6] Orthotopic heart transplantation is the treatment of choice for end stage heart disease. 7 Despite improvements overall in heart transplant outcomes over time, these improvements have not been distributed evenly across racial groups, with studies showing that despite improvements in short term survival, long term survival in African Americans and Hispanic recipients lags behind that of Caucasians.…”

“…Heart failure disproportionately affects African Americans. When compared to other ethnic groups, this group has the highest rates of heart failure and greatest mortality 1–6 . Orthotopic heart transplantation is the treatment of choice for end stage heart disease 7 .…”