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Background: Segregation index (SI) has been associated with worsened health. However, the relationship between SI within health care teams (degree of heterogeneity between teams caring for Black compared with White patients) and cardiovascular care is unclear among adequately insured populations. We sought to assess the relationship between health care team SI, patient race, receipt of care by a cardiologist, 1-year survival, and 30-day readmission rates for Black compared with White patients admitted with heart failure, ischemic heart disease, or valvular heart disease., Methods: Using Optum's de-identified Clinformatics Data Mart Database (CDM) from 2009 to 2020, generalized linear mixed-effects were used to analyze effects of patient race and SI on receipt of care by a cardiologist, and care by a cardiologist on 1-year survival and 30-day readmission., Results: Among 6572 patients (17.1% Black), the odds of receiving care by a cardiologist were 31.3% less for Black than White patients (adjusted odds ratio 0.687 [95% CI, 0.545-0.872]; P =0.001). However, there was no statistically significant association of SI on receipt of care by a cardiologist ( P =0.14). For those seen by a cardiologist, the adjusted odds ratio (Black-to-White) of 1-year survival increased with increasing SI ( P =0.02). SI had no statistically significant effect on 30-day readmission ( P =0.86)., Conclusions: Among patients hospitalized for heart failure, ischemic heart disease, or valvular heart disease, segregation of health care teams was not associated with receipt of care by cardiologists in Indiana hospitals. When cardiologists were included, the odds of 1-year survival increased for Black versus White patients with increasing segregation of clinicians, and segregation was not associated with 30-day readmission. more...

Aims: Racial disparities exist in clinical outcomes for valvular heart disease (VHD). It is unknown whether clinician segregation contributes to these disparities. Among an adequately insured population, we evaluated the relationship between clinician segregation in a hospital and receipt of care by a cardiologist according to patient race. We also evaluated the association between clinician segregation, race and care by a cardiologist on 30-day readmission and 1-year survival., Methods and Results: Using Optum's Clinformatics® Data Mart Database (CDM, US commercial and Medicare beneficiaries) from 2010 to 2018, we identified patients with a primary diagnosis of VHD. Hospitals were categorized into low, medium and high segregation groups (SG), according to clinician segregation index (SI). SI can range from 0-1 (0: the ratio of Black to White patients is the same for all clinicians; 1: each clinician treats only Black or only White patients). Outcomes were analysed using generalized linear mixed effect models. Among 8649 patients [median age 75 (67-82), 45.4% female, 16.1% Black, 83.9% White], odds of care from a cardiologist did not vary across race for all SGs [Low SG adjusted odds ratio (aOR): 0.79 (95% CI: 0.58-1.08), P = 0.14; Medium SG aOR: 0.86 (95% CI: 0.60-1.25), P = 0.43; High SG aOR: 1.07 (95% CI: 0.68-1.69), P = 0.76]. Among those that received care from a cardiologist, there was no difference in the 30-day readmission between Black and White patients across SGs [Low SG aOR: 1.05 (95% CI: 0.83-1.31), P = 0.70; Medium SG aOR: 1.22 (95% CI: 0.92-1.61), P = 0.17; High SG aOR: 0.81 (95% CI: 0.57-1.17), P = 0.27]. Among patients that did not receive care from a cardiologist, Black patients in low SG had higher odds of 30-day readmission compared to White patients [aOR: 2.74 (95%CI:1.38-5.43), P < 0.01]. Odds of 1-year survival were similar across race for all SG irrespective of receipt of care from a cardiologist [seen by a cardiologist: Low SG aOR: 1.13 (95% CI: 0.86-1.48), P = 0.38; Medium SG aOR: 0.83 (95% CI: 0.59-1.17), P = 0.29; High SG aOR: 1.01 (95% CI: 0.66-1.52), P = 0.98; not seen by a cardiologist: Low SG aOR: 0.56 (95% CI: 0.23-1.34), P = 0.19; Medium SG aOR: 0.81 (95% CI: 0.28-2.37), P = 0.70; High SG aOR: 0.63 (95% CI: 0.23-1.74), P = 0.37]., Conclusions: Among an insured population, race was not associated with care by a cardiologist for VHD or survival. Black patients not seen by cardiologists had higher odds of 30-day readmission in low clinician SG., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.) more...

Background: The number of practicing lesbian, gay, bisexual, transgender, and queer (LGBTQ+) cardiologists is unknown despite diversity initiatives focused on understanding workforce demographics., Objectives: The aim of this study was to evaluate the prevalence, sources of mistreatment, and measures of wellness among the LGBTQ+ cardiology community., Methods: An online survey was sent to the American College of Cardiology Fellow in Training and Early Career Professional Listservs and shared on social media sites. The survey included the Short-Negative Acts Questionnaire and LGBTQ+ -specific harassment questions. Chi-square analysis and Fisher exact tests were performed to compare responses between LGBTQ+ and non-LGBTQ+ respondents., Results: A total of 188 respondents completed the survey (56% Fellow in Training). One-third (33%) identified as LGBTQ+. Gender identity data included: transgender (3%), nonbinary (2%), gender queer (1%), and agender (1%). LGBTQ+ physicians were less likely to agree with the statements 'LGBTQ+ patients were treated fairly' (40% vs 66%, P  < 0.001), and 'leadership dealt with people demonstrating poor behavior fairly' (34% vs 51%, P  = 0.029) compared to heterosexual peers. LGBTQ+ physicians were more likely to report gender policing and heterosexist harassment compared to heterosexual peers ( P  = 0.002). The majority of physicians (91%) were satisfied with their decision to become a cardiologist., Conclusions: This current analysis of LGBTQ+ cardiologists in the workplace identifies opportunities to address mistreatment impacting the LGBTQ+ community. Despite experiencing mistreatment, LGBTQ+ cardiologists report high job satisfaction. Further work is necessary to create a safe space and diverse cohort of physicians required to meet the needs of LGBTQ+ patients at risk for cardiovascular disease., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2025 The Authors.) more...

Importance: Women are underrepresented in leadership positions in cardiology. Institutional grand rounds (GR) are platforms through which faculty can gain professional exposure and access to career development opportunities. The gender diversity of invited cardiology GR speakers has not been investigated., Objective: To examine the representation of women among cardiology GR speakers in the United States., Design, Setting, and Participants: This cross-sectional study reviewed all 626 internal medicine residency training program websites in the American Medical Association's FRIEDA directory to identify publicly available records of cardiology GR. Grand rounds from September 1997 through December 2022 were included; GR with more than 1 speaker and trainee-led case conferences were excluded., Exposures: Grand rounds speaker gender., Main Outcomes and Measures: Data on GR topic focus, speaker gender, and academic rank were collected., Results: A total of 3806 GR lectures at 42 institutions were included; 799 (21%) were delivered by women and 3007 (79%) by men. The proportion of women GR speakers increased by 1% per year and increased for each topic over time with the exception of electrophysiology and basic/translational science. Women were most likely to speak on women's cardiovascular health (80 lectures [10.0%] vs 17 [0.6%] for men; P < .001)., Conclusions and Relevance: Women compose about 1 in 5 cardiology GR speakers with modest growth in representation over time but remain underrepresented as GR speakers for procedural cardiology and basic/translational science topics. more...

Importance: Racial disparities in cardiovascular health, including sudden cardiac death (SCD), exist among both the general and athlete populations. Among competitive athletes, disparities in health outcomes potentially influenced by social determinants of health (SDOH) and structural racism remain inadequately understood. This narrative review centers on race in sports cardiology, addressing racial disparities in SCD risk, false-positive cardiac screening rates among athletes, and the prevalence of left ventricular hypertrophy, and encourages a reexamination of race-based practices in sports cardiology, such as the interpretation of screening 12-lead electrocardiogram findings., Observations: Drawing from an array of sources, including epidemiological data and broader medical literature, this narrative review discusses racial disparities in sports cardiology and calls for a paradigm shift in approach that encompasses 3 key principles: race-conscious awareness, clinical inclusivity, and research-driven refinement of clinical practice. These proposed principles call for a shift away from race-based assumptions towards individualized, health-focused care in sports cardiology. This shift would include fostering awareness of sociopolitical constructs, diversifying the medical team workforce, and conducting diverse, evidence-based research to better understand disparities and address inequities in sports cardiology care., Conclusions and Relevance: In sports cardiology, inadequate consideration of the impact of structural racism and SDOH on racial disparities in health outcomes among athletes has resulted in potential biases in current normative standards and in the clinical approach to the cardiovascular care of athletes. An evidence-based approach to successfully address disparities requires pivoting from outdated race-based practices to a race-conscious framework to better understand and improve health care outcomes for diverse athletic populations. more...

There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record. more...

Advancements in cardiovascular (CV) disease management are notable, yet health inequities prevail, associated with increased morbidity and mortality noted among non-Hispanic African Americans in the United States. The 2002 Institute of Medicine Report revealed ongoing racial and ethnic health care disparities, spearheading a deeper understanding of the social determinants of health and systemic racism to develop strategies for CV health equity (HE). This article outlines the strategic HE approach of the American College of Cardiology, comprising 6 strategic equity domains: workforce pathway inclusivity, health care, data, science, and tools; education and training; membership, partnership, and collaboration; advocacy and policy; and clinical trial diversity. The American College of Cardiology's Health Equity Task Force champions the improvement of patients' lived experiences, population health, and clinician well-being while reducing health care costs-the Quadruple Aim of Health Equity. Thus, we examine multifaceted HE interventions and provide evidence for scalable real-world interventions to promote equitable CV care., Competing Interests: Dr Echols has a consultation/advisory committee role for Amgen, Bayer, Boehringer Ingelheim, Merck, Regeneron, Novo Nordisk, and Novartis; and is on the Data Safety Monitoring Committees of REACT-AF. Dr Bozkurt has a consultation/advisory committee role for Abiomed, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Merck, Occlutech, Regeneron, Roche, Sanofi, scPharmaceuticals, Vifor, and Zoll/ Respicardia; and serves on the Data Safety Monitoring Committees of Liva Nova, Cardurion, Novo Nordisk, and Renovacor. Dr Ogunniyi has received institutional research grant support from AstraZeneca, 10.13039/100001003Boehringer Ingelheim, Cardurion Pharmaceuticals, and 10.13039/100004319Pfizer; and and serves on a clinical trial steering committee for 10.13039/100008272Novartis, all outside and not relevant to the contents of this manuscript. Dr Levy has a consultation/advisory committee role for Bayer, Beckman Coulter, BTG Specialty Pharmaceuticals, Cardionomics, Heart Beam, Hemisens, Medscape, Moderna, Pathfast, People.Health, Quidel Ortho, and Roche Diagnostics; is on the Data Safety Monitoring Board for Life Recovery Systems; has ownership/partnership with Alerje, Emergencies in Medicine, and My Patient Insight; and has received from 10.13039/100004319Pfizer and COVID-19 Surveillance Testing for Quest Diagnostics. Dr Bailey has a consultation/advisory board role for Novo Nordisk, OptumRX. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.) more...

The lack of diversity in the physician workforce is a multifactorial problem. From elementary school through college, students from minority or socioeconomically disadvantaged backgrounds achieve despite attending underresourced schools, facing low expectations from peers and teachers, and overcoming unconscious biases among decision makers. These and other obstacles lead to significant attrition of talent by the time cohorts prepare to apply to medical school. Pipeline initiatives that inspire and prepare applicants from groups underrepresented in medicine are needed to swell the ranks of diverse individuals entering our profession., Competing Interests: Disclosure The authors have no conflicts to disclose. There was no funding for this article., (Copyright © 2023 Elsevier Inc. All rights reserved.) more...

Background: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established., Methods: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index., Results: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P <0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P =0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index ( P interaction <0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P =0.02)., Conclusions: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities., Competing Interests: Disclosures Dr Desai is a consultant for Medtronic and Bristol Myers Squibb. He is on the executive steering committee of a trial sponsored by Bristol Myers Squibb. Dr Pandey has received grant funding outside the present study from Applied Therapeutics and Gilead Sciences; has received honoraria outside the present study as an advisor/consultant for Tricog Health Inc and Lilly, USA, Rivus, and Roche Diagnostics, and has received nonfinancial support from Pfizer and Merck. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institute on Minority Health and Health Disparities; the National Institutes of Health; or the US Department of Health and Human Services. The remaining authors have nothing to disclose. more...

Objective: To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex., Methods: We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models., Results: A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals ( P  < .001), and men had modestly higher expenses than women ($5987, P  < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P  < .001), overweight/obesity ($8816, P  < .001), smoking ($3980, P  = .009), and hypertension ($528, P  = .02) with excess spending., Conclusion: Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr Khera receives support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under award K23HL153775) and the Doris Duke Charitable Foundation (under award, 2022060). He also receives research support, through Yale, from Bristol-Myers Squibb and Novo Nordisk. He is a coinventor of U.S. Provisional Patent Applications 63/177,117, 63/428,569, and 63/346,610, unrelated to current work. He is also a founder of Evidence2Health, a precision health platform to improve evidence-based care. Dr. Pandey reports financial support was provided by GEMSSTAR Grant 1R03AG067960. Dr. Powell-Wiley reports financial support was provided by Division of Intramural Research of the National Heart, Lung, and Blood Institute and the Intramural Research Program of the National Institute on Minority Health, and Health Disparities of the NIH., (© 2023 The Author(s).) more...

In 2015, data released by the Association of American Medical Colleges (AAMC) showed that there were more Black men applying and matriculating to medical school in 1978 than 2014. The representation of Black men in medicine is a troubling workforce issue that was identified by the National Academies of Sciences, Engineering, and Medicine as a national crisis. While premedical pathway programs have contributed to increased workforce diversity, alone they are insufficient to accelerate change. In response, the AAMC and the National Medical Association launched a new initiative in August 2020, the Action Collaborative for Black Men in Medicine, to address the systems factors that influence the trajectory to medicine for Black men. The authors provide a brief overview of the educational experiences of Black boys and men in the United States and, as members of the Action Collaborative, describe their early work. Using research, data, and collective lived experiences, the Action Collaborative members identified premedical and academic medicine systems factors that represented opportunities for change. The premedical factors include financing and funding, information access, pre-health advisors, the Medical College Admission Test, support systems, foundational academics, and alternative career paths. The academic medicine factors include early identification, medical school recruitment and admissions, and leadership accountability. The authors offer several points of intervention along the medical education continuum, starting as early as elementary school through medical school matriculation, for institutional leaders to address these factors as part of their diversity strategy. The authors also present the Action Collaborative's process for leveraging collective impact to build an equity-minded action agenda focused on Black men. They describe their initial focus on pre-health advising and leadership accountability and next steps to develop an action agenda. Collective impact and coalition building will facilitate active, broad engagement of partners across sectors to advance long-term systems change., (Copyright © 2022 by the Association of American Medical Colleges.) more...

The lack of diversity in the physician workforce is a multifactorial problem. From elementary school through college, students from minority or socioeconomically disadvantaged backgrounds achieve despite attending underresourced schools, facing low expectations from peers and teachers, and overcoming unconscious biases among decision makers. These and other obstacles lead to significant attrition of talent by the time cohorts prepare to apply to medical school. Pipeline initiatives that inspire and prepare applicants from groups underrepresented in medicine are needed to swell the ranks of diverse individuals entering our profession., Competing Interests: Disclosure The authors have no conflicts to disclose. There was no funding for this article., (Copyright © 2022 Elsevier Inc. All rights reserved.) more...

Family engagement empowers family members to become active partners in care delivery. Family members increasingly expect and wish to participate in care and be involved in the decision-making process. The goal of engaging families in care is to improve the care experience to achieve better outcomes for both patients and family members. There is emerging evidence that engaging family members in care improves person- and family-important outcomes. Engaging families in adult cardiovascular care involves a paradigm shift in the current organization and delivery of both acute and chronic cardiac care. Many cardiovascular health care professionals have limited awareness of the role and potential benefits of family engagement in care. Additionally, many fail to identify opportunities to engage family members. There is currently little guidance on family engagement in any aspect of cardiovascular care. The objective of this statement is to inform health care professionals and stakeholders about the importance of family engagement in cardiovascular care. This scientific statement will describe the rationale for engaging families in adult cardiovascular care, outline opportunities and challenges, highlight knowledge gaps, and provide suggestions to cardiovascular clinicians on how to integrate family members into the health care team. more...

Over the last three decades, increased attention has been given to the representation of historically underrepresented groups within the landscape of pivotal clinical trials. However, recent events (i.e., coronavirus pandemic) have laid bare the potential continuation of historic inequities in available clinical trials and studies aimed at the care of broad patient populations. Anecdotally, cardiovascular disease (CVD) has not been immune to these disparities. Within this review, we examine and discuss recent landmark CVD trials, with a specific focus on the representation of Blacks within several critically foundational heart failure clinical trials tied to contemporary treatment strategies and drug approvals. We also discuss solutions for inequities within the landscape of cardiovascular trials. Building a more diverse clinical trial workforce coupled with intentional efforts to increase clinical trial diversity will advance equity in cardiovascular care., (Copyright © 2021. Published by Elsevier B.V.) more...

Structural racism in the United States underlies racial disparities in the criminal justice system, in the healthcare system generally, and with regards to the COVID-19 pandemic. In the year 2020, these inequities combined and magnified to such a degree that it left Black Americans and physicians caring for them questioning how much Black lives matter. Academic medical centers and the major cardiology organizations responded to a global call to end racism with bold statements and initiatives. Interventional cardiologists utilize advanced equipment to mechanically treat a wide spectrum of heart problems, yet this technology has not been applied in an equitable manner. Interventional therapies are often underutilized in Blacks, exacerbating healthcare disparities and contributing to the excess cardiovascular morbidity and mortality in these communities. Racial bias, whether intentional, unconscious, systemic, or at the individual level, plays a role in these disparities. Many in the interventional cardiology community aspire to take intentional steps to reduce the impact of bias and racism in our specialty. We discuss several proposals here and provide a "report card" for interventional programs to perform a self-assessment., (© 2021 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.) more...

Background Black men are burdened by high cardiovascular risk and the highest all-cause mortality rate in the United States. Socioeconomic status (SES) is associated with improved cardiovascular risk factors in majority populations, but there is a paucity of data in Black men. Methods and Results We examined the association of SES measures including educational attainment, annual income, employment status, and health insurance status with an ideal cardiovascular health (ICH) score, which included blood pressure, glucose, cholesterol, body mass index, physical activity, and smoking in African American Male Wellness Walks. Six metrics of ICH were categorized into a 3-tiered ICH score 0 to 2, 3 to 4, and 5 to 6. Multinomial logistic regression modeling was performed to examine the association of SES measures with ICH scores adjusted for age. Among 1444 men, 7% attained 5 to 6 ICH metrics. Annual income <$20 000 was associated with a 56% lower odds of attaining 3 to 4 versus 0 to 2 ICH components compared with ≥$75 000 ( P =0.016). Medicare and no insurance were associated with a 39% and 35% lower odds of 3 to 4 versus 0 to 2 ICH components, respectively, compared with private insurance (all P <0.05). Education and employment status were not associated with higher attainment of ICH in Black men. Conclusions Among community-dwelling Black men, higher attainment of measures of SES showed mixed associations with greater attainment of ICH. The lack of association of higher levels of educational attainment and employment status with ICH suggests that in order to address the long-standing health inequities that affect Black men, strategies to increase attainment of cardiovascular health may need to address additional components beyond SES. more...

Racism and racial bias influence the lives and cardiovascular health of minority individuals. The fact that minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review, we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the United Kingdom, and the US, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty., (© 2021 The Authors.) more...

The coronavirus disease pandemic and the growing movements for social and racial equality have increased awareness of disparities in American health care that exist on every level. Social determinants of health, structural racism, and implicit bias play major roles in preventing health equity. We begin with the larger picture and then focus on examples of systemic and health inequities and their solutions that have special relevance to allergy-immunology. We propose a 4-prong approach to address inequities that requires (1) racial and ethnic inclusivity in research with respect to both participants and investigators, (2) diversity in all aspects of training and practice, (3) improvement in communication between clinicians and patients, and (4) awareness of the social determinants of health. By communication we mean sensitivity to the role of language, cultural background, and health beliefs in physician-patient interactions and provision of training and equipment so that the use of telecommunication can be a resource for all patients. The social determinants of health are the social factors that affect health and the success of health care, such as adequacy of housing and access to nutritious foods. Using this 4-prong approach we can overcome health disparities., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.) more...

Racism and events of racial violence have dominated the US news in 2020 almost as much as the novel coronavirus pandemic. The resultant civil unrest and demands for racial justice have spawned a global call for change. As a subset of a society that struggles with racism and other explicit biases, it is inescapable that some physicians and health-care employees will have the same explicit biases as the general population. Patients who receive care at academic medical centers interact with multiple individuals, some of whom may have explicit and implicit biases that influence patient care. In fact, multiple reports have documented that some physicians, health-care workers, and health professional students have negative biases based on race, ethnicity, obesity, religion, and sexual identity, among others. These biases can influence decision-making and aggravate health-care disparities and patient-physician mistrust. We review four actual cases from academic medical centers that illustrate how well-intended physicians and health-care workers can be influenced by bias and how this can put patients at risk. Strategies to mitigate bias are discussed and recommended. We introduce what we believe can be a powerful teaching tool: periodic "bias and racism rounds" in teaching hospitals, in which real patient interactions are reviewed critically to identify opportunities to reduce bias and racism and to attenuate the impact of bias and racism on patient outcomes., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.) more...

Background The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce. Methods and Results To assess program directors' perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty-three percent of respondents agreed that "our program is diverse already so diversity does not need to be increased." Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list. Conclusions These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs. more...

Background: Survival rates for out-of-hospital cardiac arrest are very low and neurologic recovery is poor. Innovative strategies have been developed to improve outcomes. A collaborative extracorporeal cardiopulmonary resuscitation (ECPR) program for out-of-hospital refractory pulseless ventricular tachycardia (VT) and/or ventricular fibrillation (VF) has been developed between The Ohio State University Wexner Medical Center and Columbus Division of Fire., Methods: From August 15, 2017, to June 1, 2019, there were 86 patients that were evaluated in the field for cardiac arrest in which 42 (49%) had refractory pulseless VT and/or VF resulting from different underlying pathologies and were placed on an automated cardiopulmonary resuscitation device; from these 42 patients, 16 (38%) met final inclusion criteria for ECPR and were placed on extracorporeal membrane oxygenation (ECMO) in the cardiac catheterization laboratory (CCL)., Results: From the 16 patients who underwent ECPR, 4 (25%) survived to hospital discharge with cerebral perfusion category 1 or 2. Survivors tended to be younger (48.0 ± 16.7 vs. 59.3 ± 12.7 years); however, this difference was not statistically significant ( p =0.28) likely due to a small number of patients. Overall, 38% of patients underwent percutaneous coronary intervention (PCI). No significant difference was found between survivors and nonsurvivors in emergency medical services dispatch to CCL arrival time, lactate in CCL, coronary artery disease severity, undergoing PCI, and pre-ECMO PaO 2 , pH, and hemoglobin. Recovery was seen in different underlying pathologies., Conclusion: ECPR for out-of-hospital refractory VT/VF cardiac arrest demonstrated encouraging outcomes. Younger patients may have a greater chance of survival, perhaps the need to be more aggressive in this subgroup of patients., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Konstantinos Dean Boudoulas et al.) more...

In an attempt to help us navigate a complex world, our unconscious minds make certain group associations on the basis of our experiences. Physicians are not immune to these implicit associations or biases, which can lead physicians to unknowingly associate certain demographic groups with negative concepts, like danger, noncompliance, and lower competence. These biases can influence clinical decision making in ways that potentially harm patients and may unfairly influence the medical school, residency, and fellowship application processes for candidates in certain underrepresented groups. To minimize the potential negative impact of implicit biases on patient care and diversity in the medical profession, physician-leaders have a responsibility to understand biases and how to consciously override them. This article discusses the potential impact of implicit bias in health care and student/trainee selection and reviews research-proven tools to reduce implicit bias in one-on-one interactions., (Copyright © 2020 by the American Thoracic Society.) more...

Background: Unplanned hospital readmissions are an important quality metric for benchmarking, but there are limited data following an acute myocardial infarction (AMI). This study aims to examine the 30-day unplanned readmission rate, predictors, causes and outcomes after hospitalization for AMI., Methods: The USA Nationwide Readmission Database was utilized to analyze patients with a primary diagnosis of AMI between 2010 and 2014. Rates of readmissions, causes and costs were determined and multiple logistic regressions were used to identify predictors of readmissions., Results: Of 2 204 104 patients with AMI, the 30-day unplanned readmission rate was 12.3% (n = 270 510), which changed from 13.0 to 11.5% between 2010 and 2014. The estimated impact of readmissions in AMI was ~718 million USD and ~281000 additional bed days per year. Comorbidities such as diabetes [odds ratio (OR) 1.27, 95% confidence interval (CI) 1.25-1.29], chronic lung disease (OR 1.29, 95% CI 1.26-1.31), renal failure (OR 1.38, 95% CI 1.35-1.40) and cancer (OR 1.35, 95% CI 1.30-1.41) were independently associated with unplanned readmission. Discharge against medical advice was the variable most strongly associated with unplanned readmission (OR 2.40, 95% CI 2.27-2.54). Noncardiac causes for readmissions accounted for 52.9% of all readmissions. The most common cause of cardiac readmission was heart failure (14.3%) and for noncardiac readmissions was infections (8.8%)., Conclusion: Readmissions during the first month after AMI occur in more than one in 10 patients resulting in a healthcare cost of ~718 million USD per year and ~281000 additional bed days per year. These findings have important public health implications. Strategies to identify and reduce readmissions in AMI will dramatically reduce healthcare costs for society. more...

Collaborative research between the University School of Medicine Office of Diversity and Inclusion, Health Sciences Library and Department of African and African American Studies recently identified Dr. Charles Edgar Newsome as the institution's first African American physician graduate in 1893. Born May 25, 1856 in the town of Buffalo within Putnam County of Northwest Virginia, he served for 3 years and 6 months as a member of the Regimental Band of the United States Army 25th Infantry, also known as the Buffalo Soldiers, became Grand Master of the Grand United Order of Odd Fellows, and served communities of the state as a reverend, physician, and civic leader. Archival records and photographs uncover the remarkable life of Reverend Charles Edgar Newsome, MD, a hidden figure in history., (Copyright © 2020 National Medical Association. Published by Elsevier Inc. All rights reserved.) more...

Objective: This study aims to investigate the temporal trends in utilization of invasive coronary angiography (CA) at different time points and changing profiles of patients undergoing CA following non-ST-elevation acute coronary syndrome (NSTEACS). We also describe the association between time to CA and in-hospital clinical outcomes., Patients and Methods: We queried the National Inpatient Sample to identify all admissions with a primary diagnosis of NSTEACS from 2004 to 2014. Patients were stratified into early (day 0, 1), intermediate (day 2) and late strategy (day≥3) according to time to CA. Multivariable logistic regression was used to investigate the association between time to CA and in-hospital mortality, major bleeding, stroke and Major Adverse Cardiac and Cerebrovascular Events., Results: A total of 4 380 827 records were identified with a diagnosis of NSTEACS, out of which 57.5% received CA. The proportion of patients undergoing early CA increased from 65.6 to 72.6%, whereas late CA commensurately declined from 19.6 to 13.5%. Patients receiving early CA were younger (age: 64 vs. 70 years), more likely to be male (63.7 vs. 55.3%) and of Caucasian ethnic background (68.7 vs. 64.7%) compared with late CA group. Similarly, Women, weekend admissions and African Americans remain less likely to receive early CA. In-hospital mortality was lowest in the intermediate group (odds ratio=0.30, 95% confidence interval: 0.28-0.33)., Conclusion: Use of early CA has increased in the management of NSTEACS; however, there remain significant disparities in utilization of an early invasive approach in women, African Americans, admission day and older patients in the USA. more...

Background: Obesity and cancer are two common diseases in the United States. Although there is an interaction of obesity and cancer, little is known about surgeon perceptions and practices in the care of obese cancer patients. We sought to characterize perceptions and practices of surgical oncologists regarding the perioperative care of obese patients being treated for cancer., Methods: A cross-sectional survey was designed, pilot tested, and utilized to assess perceptions and practices of surgeons treating cancer patients. Surgical oncologists were identified using a commercially available database, and Qualtrics ® was used to distribute and manage the survey. Statistical analyses were completed by using SPSS., Results: Of the 1731 electronic invitations, 172 recipients initiated the survey, and 157 submitted responses (91.2%). Many surgeons (65.7%) believed that obese patients are more likely to present with more advanced cancers and were more likely than system factors to explain this delayed treatment [t(87) = 4.84; p < 0.001]. Nearly two-thirds of providers (64.5%) reported that obesity had no impact on the timing of surgery; however, one-third of respondents (34.2%) were more likely to recommend preoperative nonsurgical therapy rather than upfront surgery among obese patients. For operations of the chest/abdomen and breast/soft tissue, surgeons perceived obesity to be more related to risk of postoperative than intraoperative complications (chest/abdomen mean 4.13 vs. 3.26; breast/soft tissue 4.11 vs. 2.60; p < 0.001)., Conclusions: One in three surgeons reported that patient obesity would change the timing/sequence of when resection would be offered. Many surgeons perceived that obesity was related to a wide array of intra- and postoperative adverse outcomes. more...

Spontaneous coronary artery dissection, a rare cause of acute coronary syndrome, is due to nonatherosclerotic coronary events and is probably underrecognized as a cause of myocardial infarction. The condition typically affects premenopausal women who are otherwise healthy. Among more than 1,200 reported cases, recurrent dissection has been described 63 times, and only 3 reports have documented multiple episodes of dissection involving different vascular territories. We present the case of a woman in her 30s who, over a 9-year period, presented 4 times with coronary dissection in different vascular territories. She was first treated conservatively, then with stents, and ultimately by means of coronary artery bypass grafting. In addition to this case, we discuss this rare condition and its management. more...

The relative lack of diversity in medicine is a rate limiting factor in efforts to eliminate health care disparities. Many medical schools struggle to matriculate student bodies that reflect the diversity of this country. Actively recruiting is one tactic to diversify a medical school's applicant pool, but in isolation is not enough. Our medical school admissions committee made a number of programmatic changes that contributed to our current compositional diversity that may be instructive to others. This report from the field on the experience of one U.S. medical school describes several admissions committee initiatives that can be undertaken to increase the yield of students from groups underrepresented in medicine who matriculate to medical school. more...

Problem: Implicit white race preference has been associated with discrimination in the education, criminal justice, and health care systems and could impede the entry of African Americans into the medical profession, where they and other minorities remain underrepresented. Little is known about implicit racial bias in medical school admissions committees., Approach: To measure implicit racial bias, all 140 members of the Ohio State University College of Medicine (OSUCOM) admissions committee took the black-white implicit association test (IAT) prior to the 2012-2013 cycle. Results were collated by gender and student versus faculty status. To record their impressions of the impact of the IAT on the admissions process, members took a survey at the end of the cycle, which 100 (71%) completed., Outcomes: All groups (men, women, students, faculty) displayed significant levels of implicit white preference; men (d = 0.697) and faculty (d = 0.820) had the largest bias measures (P < .001). Most survey respondents (67%) thought the IAT might be helpful in reducing bias, 48% were conscious of their individual results when interviewing candidates in the next cycle, and 21% reported knowledge of their IAT results impacted their admissions decisions in the subsequent cycle. The class that matriculated following the IAT exercise was the most diverse in OSUCOM's history at that time., Next Steps: Future directions include preceding and following the IAT with more robust reflection and education on unconscious bias. The authors join others in calling for an examination of bias at all levels of academic medicine. more...

Background: Assessment of the femoral and iliac arteries is essential prior to transcatheter aortic valve replacement (TAVR). It is critical for establishing candidacy for a femoral approach, and can help predict vascular complications. Although computed tomography angiography (CTA) is the standard imaging modality, it has limitations., Objective: This study compared CTA with intravascular ultrasound (IVUS) in patients undergoing TAVR evaluation., Methods: Fifteen patients undergoing pre-TAVR coronary angiography and hemodynamic assessment were recruited. Following coronary angiography, patients underwent distal aortography, bilateral iliac and femoral arteriography, and IVUS assessment. Vascular tortuosity, minimum lumen diameter, and cross-sectional area were obtained and the findings were compared with those obtained from CTA., Results: Correlation between IVUS and CTA was strong for minimum luminal diameter (r=0.62). Concordance was also strong between CTA and invasive iliofemoral angiography for assessment of tortuosity (r=0.75). Utilizing Bland-Altman analysis, vessel diameters obtained by IVUS were consistently greater than those obtained by CTA. The angiography and IVUS strategy was associated with a lower overall mean contrast utilization (29 cc vs 100 cc; P<.001), reduced mean radiation exposure (527 mGy vs 998 mGy; P=.045), and no significant difference in mean test duration (13.3 minutes vs 10 minutes; P=.12)., Conclusions: For femoral and iliac arterial assessment prior to TAVR, IVUS is a viable alternative to CTA with comparable accuracy, and the potential for less contrast use and less radiation exposure. IVUS is also a valuable adjunct to CTA in patients with borderline femoral access diameters or considerable CTA artifacts. more...

Purpose: African American (AA) physicians are more likely to practice primary care and care for underserved populations than majority physicians, yet remain underrep-resented in medicine. Because Historically Black Colleges and Universities (HBCUs) have a legacy of matriculating students with lower standardized test scores, majority medical schools may be reluctant to form pipelines with HBCUs. We compared academic and postgraduate performance of two groups of AA students at The Ohio State University College of Medicine: HBCU versus Predominantly White Institutions (PWI) graduates., Methods: We identified 212 AA matriculants between 1992 and 2007. Group 1 (N=39) were HBCU graduates, Group 2 (N=173) were PWI graduates. We compared MCAT scores, medical school, and post-graduate performance., Results: Despite lower average MCAT scores, groups did not differ significantly in terms of graduating, matching into residencies, selecting primary care, or achieving board certification., Conclusions: Majority medical schools should consider forming strong recruitment pipelines with HBCUs. more...

The use of transradial coronary angiography and intervention is growing because of its advantages over the femoral approach. However, the small size of the radial artery can contribute to complications. We present a case of an in situ access complication of transradial coronary artery catheterization. It is important for the anesthesiologist to know about the short-term and long-term consequences of this intervention, which could lead to narrowing of the artery even beyond the site of puncture. Understanding these changes could help anesthesiologists make better decisions about using the radial artery for monitoring after transradial coronary artery catheterization procedures. more...

Cardiac catheterization has several risks, notably which include bleeding, stroke and death. The transradial (TR) approach to catheterization is associated with a lower bleeding risk. The right radial approach is the default method in most laboratories and the left radial artery (LRA) serves as the bail-out approach. This article discusses the advantages and disadvantages of transfemoral and TR access routes. The authors envisage an increased adoption of the LRA approach, due to the anatomical superiority and ease of catheter engagement afforded by this approach. The authors discuss ways to increase operator ease for LRA in the laboratory and propose a novel way to improve LRA work-flow. more...

Background: Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage., Methods: A 48-year-old, devout Jehovah's Witness, woman with a history of coronary artery bypass surgery presented with a non-ST-segment elevation acute myocardial infarction. Pretransfer catheterization demonstrated a heavily calcified, 90% distal left main stenosis with an occluded left internal mammary artery graft to the left anterior descending coronary artery. To minimize the risk of bleeding requiring a blood transfusion, a coronary rotational atherectomy via a TR was performed. A nonhydrophilic, 7F sheath was used to accommodate the larger rotational atherectomy burr sizes. The coronary procedure was successful, but the sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. Post procedure she developed a hematoma with motor and neurological deficits of her hand., Results: Emergent surgical exploration with fasciotomy was planned. The radial artery was explored and found to be redundant and pulseless, prompting proximal evaluation and revealing complete avulsion of the radial artery at its origin. An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch and surgical ligation of the radial artery was conducted., Conclusion: Vascular surgeons need to be aware of potential complications related to TR which are likely to increase as this method is more widely disseminated., (Copyright © 2015 Elsevier Inc. All rights reserved.) more...

Background: A large volume of literature has documented racial disparities in the delivery of cardiovascular care in the United States and that decreased access to procedures and undertreatment lead to worse outcomes. A lack of diversity among physicians is considered to be a major contributor. The fellowship training program in cardiovascular medicine at The Ohio State University Medical Center had never trained a fellow from a minority group underrepresented in medicine (URM) before 2007., Intervention: In 2005, the fellowship made it a priority to recruit and match URM candidates in an effort to address the community's lack of diversity and disparities in cardiovascular care., Methods: Program leaders revised the recruitment process, making diversity a high priority. Faculty met with members of diverse residency programs during visits to other institutions, the focus of interview day was changed to highlight mentorship, additional targeted postinterview communications reached out to highly competitive applicants, and a regular mentoring program was constructed to allow meaningful interaction with URM faculty and fellows., Results: Since these changes were implemented, the program has successfully matched a URM fellow for 5 consecutive years. Such candidates currently make up 4 of 16 total trainees (25%) in the fellowship in cardiovascular medicine., Conclusions: The cardiovascular medicine fellowship training program at The Ohio State University was able to revise recruitment to attract competitive URM applicants as part of a concerted effort. Other educational programs facing similar challenges may be able to learn from the university's experiences. more...

Objective: Compare vascular complications and incidence of bleeding of Impella 2.5 and intra-aortic balloon pump (IABP) in high-risk percutaneous coronary interventions (PCI)., Background: Large arterial sheath size for device insertion is associated with vascular and/or bleeding complications; gastrointestinal bleeding may also occur with anti-coagulation use., Methods: Patients with an acute coronary syndrome receiving Impella 2.5 or IABP during high-risk PCI were studied (13 Impella; 62 IABP). Vascular complications and incidence of bleeding were compared., Results: Post-procedure hematocrit was similar between groups. Blood transfusion occurred in 38.4% and 32.2% of patients in the Impella and IABP groups, respectively (P = NS); 65.3%, 30.7% and 3.8% of bleeding were due to vascular access site/procedure related, gastrointestinal and genitourinary, respectively. There was no statistical significant difference in vascular complications between the Impella and IABP groups (15.3% and 6.4% of patients, respectively); mesenteric ischemia (n = 1) and aortic rupture (n = 1) were only in the IABP group. In-hospital and one-year mortality were not statistically significant between groups., Conclusion: Impella can be used as safely as IABP during high-risk PCI with similar vascular and bleeding complications. Importantly, approximately one third of bleeding was from the gastrointestinal system warranting careful prophylactic measures and monitoring. more...

Upper extremity arteries are affected by occlusive diseases from diverse causes, with atherosclerosis being the most common. Although the overriding principle in managing patients with upper extremity arterial occlusive disease should be cardiovascular risk reduction by noninvasive and pharmacologic means, when target organ ischemia produces symptoms or threatens the patient's well-being, revascularization is necessary. Given their minimally invasive nature and successful outcomes, percutaneous catheter-based therapies are preferred to surgical approaches. The fact that expertise in these techniques resides in not one but several disciplines (vascular surgery, radiology, cardiology, vascular medicine) makes this an area ripe for multidisciplinary collaboration to the benefit of patients., (Copyright © 2011 Elsevier Inc. All rights reserved.) more...