Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9
JACC Focus Seminar
Central Illustration
Abstract
Heart failure (HF) affects >6 million Americans, with variations in incidence, prevalence, and clinical outcomes by race/ethnicity. Black adults have the highest risk for HF, with earlier age of onset and the highest risk of death and hospitalizations. The risk of hospitalizations for Hispanic patients is higher than White patients. Data on HF in Asian individuals are more limited. However, the higher burden of traditional cardiovascular risk factors, particularly among South Asian adults, is associated with increased risk of HF. The role of environmental, socioeconomic, and other social determinants of health, more likely for Black and Hispanic patients, are increasingly recognized as independent risk factors for HF and worse outcomes. Structural racism and implicit bias are drivers of health care disparities in the United States. This paper will review the clinical, physiological, and social determinants of HF risk, unique for race/ethnic minorities, and offer solutions to address systems of inequality that need to be recognized and dismantled/eradicated.
Highlights
| • | HF is more prevalent among Black adults than in individuals of other races, with earlier onset and high rates of hospitalization and death. | ||||
| • | Environmental and socioeconomic factors, and other social determinants of health are independent risk factors for incident HF and adverse outcomes, and data from pragmatic trials demonstrate that disparities in care can be overcome. | ||||
| • | Clinicians must recognize and address disparities within systems of CV care based on race and/or ethnicity to eliminate bias and improve outcomes. | ||||
Introduction
Heart failure (HF) remains the most common diagnosis for hospitalized patients ≥65 years of age. Similar to the U.S. population, the sex, race, and ethnicity of HF is equally heterogeneous. The most commonly reported races in the literature are White and Black (13% of the total population) populations. Ethnicities are abundant, with the Hispanic population being the most prominent (16%), followed by Asian populations (5.6%). Within each racial and ethnic group, there is also heterogeneity, seldom sought or reported in studies. HF may preferentially affect various racial and ethnic subpopulations because of differences in risk factors, with Black patients having a high burden of hypertension (HTN), whereas some Hispanic groups have a high prevalence of diabetes mellitus (DM). In addition to these risk factors, environmental influences and other socioeconomic factors, which are more common in race/ethnic minorities, play a role in the prevalence and incidence of HF and in poor outcomes.
When compared with other groups, HF disproportionately affects Black persons, who are more likely to be diagnosed at younger ages (1,2). The age-adjusted death rate for HF is highest in Black men (118.2 per 100,000), followed by non-Hispanic White men (111.3 per 100,000), Black women (86.0 per 100,000), and White women (80.4 per 100,000) (1). Similarly, the rate of HF hospitalization for Black persons is nearly 2.5-fold higher when compared with White persons (3). Furthermore, Black patients have longer lengths of stay and higher 90-day readmission rates than other racial groups (2). The past 20 years have witnessed an explosion of both drug and device therapeutic options, particularly in HFrEF, but despite these successes, important disparities persist in clinical outcomes. This is in part caused by care access, costs of new medications, and critical discrepancies in the composition of populations enrolled in clinical trials by race/ethnicity. Studies often pledge to enroll minorities but fall short in developing plans to do so, and fall even shorter in the results, often with apologies about their own deficiencies.
Nonetheless, although differences in physiology, either genetic or environmental, may exist, disparities in care delivery are never acceptable. In 2002, the Institute of Medicine published its report Unequal Treatment: Confronting Racial and Ethnic Disparities in HealthCare, opening a dialogue about disparities of care (4). The conversation has never been more important than it is today. This document will address the intersection of race/ethnicity and HF and will include epidemiology, an examination of social determinants of health (SDOH) and structural racism, patient experience by race/ethnicity, known disparities of care, and the role of clinical practice guidelines (CPG). Solutions will be offered for the reader to consider. Categories of race/ethnicity will reflect the social construct used by the U.S. Office of Management and Budget, whereby White = Caucasian; Black = African American; Hispanic will be the preferred term for “Latin X/Latinos”; and Asian, also a widely heterogenous population, will be referred as one: Asian. Sex differences in HF are not addressed, and although critically important, are suggested for additional publications.
Epidemiology
Although HF is expected to affect >8 million (or ∼3%) of Americans by the year 2030, important differences in incidence and prevalence exist based on race/ethnicity. Compared with other race/ethnic groups, Black individuals have the highest incidence and prevalence of HF (3,5). An analysis from the MESA (Multi-Ethnic Study of Atherosclerosis) estimated the incidence of HF as 4.6 per 1,000 person-years in non-Hispanic Black persons, 3.5 per 1,000 person-years in Hispanic persons, compared with 2.4 per 1,000 person-years in non-Hispanic White persons and 1.0 per 1,000 person-years in Chinese-American persons (6) (Figure 1). The higher burden of HF in Black adults exists for both HFrEF as well as HF with preserved ejection fraction (5). Black patients have the highest risk of HF-related hospitalization and death (2). Although disparities in the rate of HF hospitalization for Hispanic patients appear to be decreasing with time, the rate of HF hospitalization for Black men and women is nearly 2.5-fold higher than the rate of HF hospitalization for White adults, with no change in the disparity in nearly a decade (2). Asian adults have a lower rate of HF hospitalization compared with other race/ethnic groups.
Cumulative Hazards for HF by Racial/Ethnic Group in MESA
Black participants (African Americans) had the highest incident rate of heart failure (HF). Hispanic participants were the second highest, followed by White and Chinese (4.6, 3.5, 2.4, and 1.0 per 1,000 person-years, respectively). Univariable analysis with a difference in the cumulative hazard of HF among the 4 groups: log rank test P = 0.01. Adapted from Bahrami et al (6).
Traditional CV Risk Factors
Much of the increased burden of HF in Black and Hispanic adults, although not all, is driven by a higher prevalence of traditional cardiovascular (CV) risk factors. HTN is by far the strongest risk factor for incident HF in Black patients, although other risk factors including obesity, DM, and physical inactivity are more common in Black compared with White patients (7,8). In Hispanic populations, the process of acculturation has been associated with higher prevalence of obesity, sedentary lifestyle, HTN, and DM (9,10). Recent analyses from the National Health and Nutrition Examination Survey demonstrate that the proportion of hypertensive U.S. adults with blood pressure controlled to guidelines has declined in recent years, in part caused by inadequate blood pressure control among Black individuals (11,12). Data on HF in Asian-American populations are more limited. However, the higher burden of coronary artery disease, DM, and obesity, particularly among South Asian individuals, is associated with increased risk of HF (7,13).
Lifestyle indicators, such as physical inactivity, alcohol, and substance abuse, vary significantly among racial and ethnic groups and have complex origins (14). Lower prevalence of healthy lifestyle behaviors in Black and Hispanic adults contributes to the higher prevalence of CV risk factors in these subgroups. Only 1 in 10 Black adults have at least 5 CV health metrics at ideal levels, compared with 1.3 in 10 Hispanic adults, and ∼1.8 in 10 non-Hispanic White adults, with Black and Hispanic women being at particularly high risk for absent healthy lifestyle behaviors (8) (Figure 2). SDOH, structural racism, and neighborhood environment, addressed in the next section, also contribute to the prevalence of traditional CV risk factors, and ultimately the incidence and prevalence of HF by limiting the opportunities for healthy lifestyle behaviors for individuals from low socioeconomic status (SES) and minority subgroups. A recent analysis from the Jackson Heart Study demonstrated that Black participants with more stress from lifetime racial discrimination were more likely to engage in unhealthy behaviors, and adjustment for those behaviors (tobacco and alcohol use, poor diet, and physical inactivity) attenuated the association between stress and the risk of incident hypertension (15). The unique experience of discrimination related to African hair textures may contribute to reduced participation in vigorous exercise to achieve and maintain prevailing beauty standards, further exacerbating the high prevalence of overweight and obesity among Black women. Thus, providers must have cultural sensitivity when addressing the root origins of unhealthy lifestyle behaviors.
Estimates of Adults Meeting Ideal Component Criteria of CV Health
Age-standardized prevalence estimates of U.S. adults ≥20 years of age meeting ideal criteria for different numbers of components of CV health, overall and by race/ethnicity, 2013 to 2014. Error bars represent 95% CI. NH = non-Hispanic. Source with permission from American Heart Association tabulation using National Health and Nutrition Examination Survey, 2013 to 2014.
SDOH and Structural Racism
Black and Hispanic individuals are more likely to be affected by SDOH, including socioeconomic position, decreased social support, reduced access to health care, and poor residential environment, which are associated with incident HF through nontraditional mechanisms (16). Structural racism refers to racial discrimination that is fostered by laws and practices, sanctioned and implemented by various levels of government, and embedded in the economic system as well as in cultural and societal norms (17). Structural racism disproportionately limits opportunities for social, economic, and financial advancement for race/ethnic minorities, which in turn results in negative health outcomes (Central Illustration).
Pathways Between Structural Racism and Health Care Disparities in Heart Failure
Structural racism can impact health care disparities and adverse health outcomes for patients with heart failure through various mechanisms, including state-sanctioned violence, residential segregation, unequal employment, and unequal health care. Structural racism limits opportunities for social and economic advancement primarily for people of color, which can have a multitude of negative consequences on health. CPG = clinical practice guidelines.
Income inequality
Race/ethnic minorities are over-represented in lower SES, and over time, wealth inequality has accelerated along racial and ethnic divides (18). Workers of color are far more likely to be paid poverty-level wages than White workers (19), which can affect salary and potentially benefits, including health insurance and subsequent access to medical care and medications. Patients with low income are more likely to experience HF (adjusted relative risk reported to be as high as 50%), as are patients with lower educational attainment (20). More broadly, lower SES is associated with decreased survival (21). Low health literacy, more common among Black and Hispanic patients with HF, is predictive of higher risk of death and hospitalization (22). Geographic disparities in heart disease and specifically HF are another mechanism that explains observed racial and ethnic disparities (16).
Violence and mass incarceration in communities
The stress content of an environment also plays a role as part of SDOH. Although often not included as an environmental issue, there is a clear link between increased neighborhood violence, police encounters/use of force, and chronic disease with early mortality. Black persons are more likely than White persons to report stress as a result of encounters with the police, an important factor knowing the well-documented association between stress and risk factors for chronic disease and early mortality. Furthermore, Black persons experience more physical violence by police that leads to higher rates of injury and death. In communities with a high level of frisking, Sewell et al (23) found increased levels of PTSD, nervousness, and mental stress not only by those touched directly by the law system but also others within the community. Sewell and Jefferson (24) further studied illness related to police presence in multiracial communities and found that living in minority communities with a high concentration of police force toward pedestrians was associated with a higher risk of DM and obesity, risk factors that are associated with incident HF. Decreased social support in the community is a result of police violence and mass incarceration whether directly or indirectly. The importance of adequate social support has been demonstrated in Black patients with HF specifically, with married Black patients and those living with family having lower mortality and readmission rates than single Black patients or those who live alone. Due to concerns of violence in neighborhoods of smaller cities, suburbs and exurbs where underserved communities live displaced from major urban centers have limited capacity for addressing community trauma in part because of less access to community workers.
Neighborhood environment and residential segregation
Black and Hispanic individuals are significantly more likely to live in impoverished neighborhoods because of historic practices such as redlining, as well as modern day practices including racial steering, exclusionary zoning, and predatory lending practices by banking institutions (18). Neighborhood of residence is increasingly recognized as an independent predictor of an individual’s health, because persons living in more impoverished and racially segregated neighborhoods are more likely to develop HTN, DM, and obesity (16,21). However, area deprivation is associated with a higher risk of incident cardiovascular disease (CVD) and HF even after adjusting for traditional CV risk factors, suggesting that neighborhood-related risks for poor CV outcomes are not fully explained by CV risk factors alone (21). A recent analysis of >30,000 Black and White patients with HF in the Southeastern United States demonstrated a higher risk of HF readmissions and death among Black patients across quartiles of the Social Deprivation Index that was not accounted for by traditional CV risk factors (25). Although there was increased risk of adverse clinical outcomes with increasing neighborhood deprivation, excess risk of HF readmission could be demonstrated even for Black patients living in neighborhoods with the least deprivation. The Women’s Health Initiative found that the excess risk of incident HF among Black women was primarily attributable to lower household income and DM (26). Lower individual and neighborhood SES are associated with worse diet quality and higher consumption of processed foods that have higher levels of inorganic phosphates. Inorganic phosphate consumption may, in turn, mediate increased risk of HTN, left ventricular hypertrophy, and HF via increased levels of fibroblast growth factor-23 (27). As South Asian adults in the United States comprise a unique group with high income and educational attainment, the risk of HF from traditional CV risk factors may be offset by the diminished effect of SDOH (28). The impact of these issues on particular racial and ethnic groups needs further research, including finding equitable and successful solutions.
Racial and Ethnic Disparities of Care
Despite major advances in medicine, disparities in health and health care persist by race, ethnicity, geography, and SES (29). Factors contributing to health disparities occur at all levels, from patient to provider, in communities, and even on a larger scale, as in health care systems and public policy (3).
Implicit bias
Black adults have an excess burden of CVD compared with White adults that persists even after adjustment for SES and other known CVD risk factors. Racial disparities are striking with regard to how often race/ethnic minority patients are less likely to be referred for implantable cardioverter-defibrillators, cardiac resynchronization therapy, mechanical circulatory support (MCS), and heart transplantation (8).
Black, Hispanic, and Asian patients are more likely than White patients to perceive health care system bias, leading to less trust and confidence in their provider and less satisfaction with care (27-29). Multiple studies have documented how clinicians’ feelings of “dark-skin” bias affect clinical decision making, including decreased referral for cardiac catheterization, thrombolysis, and heart transplantation (30,31).
A growing body of literature demonstrates that implicit bias, embedded stereotypes that lie beneath the surface of consciousness, influences clinical decision-making and may operate to disadvantage vulnerable populations and worsen health disparities. In a recent review, 31 of 37 studies examining implicit bias over the last decade demonstrated “evidence of pro-White or anti-Black, Hispanic, American Indian or dark-skin bias among a variety of health care providers across multiple levels of training and disciplines” (32). Black patients, in particular, are more likely to be perceived by health care providers as less compliant, less intelligent, and less cooperative than their White counterparts. Health care providers are less likely to have feelings of affiliation toward Black patients (33). Moreover, Black patients perceive worse treatment in regard to patient centeredness, contextual knowledge of the patient, and patient-provider communications from providers who demonstrate implicit bias on the Implicit Association Test (34).
Patient-level challenges
At the patient level, genetic factors contribute to health disparities. Beyond race/ethnic differences in traditional risk factors, questions remain as to whether differential physiology exists based on ancestry that contribute to increased risk of HF. Prior studies have demonstrated that Black adults have impaired endothelium-dependent and -independent vasodilation compared with White adults (35). A relative deficiency of natriuretic peptides has been noted in Black, Hispanic, and Chinese-American patients compared with White patients, and may be associated with multiple adverse phenotypes, including endothelial dysfunction, HTN, left ventricular hypertrophy, and salt and fluid retention (36). Despite most contemporary HF clinical trials having relatively stringent natriuretic peptide criteria for inclusion, it remains unclear whether thresholds based on ancestry should be taken into account. Moreover, Black and Hispanic patients may be less likely to be offered genetic testing for HF etiology. The higher risk for developing HF with preserved ejection fraction in Black persons is influenced by a higher burden of traditional risk factors, but also by the prevalence of the valine-to-isoleucine substitution at position 122 (V122I) on chromosome 18 which is carried by 3.5% of Black persons and associated with higher risk for development of transthyretin (aTTR)-related cardiac amyloidosis (37). Despite widespread recognition that is strongly associated with the risk of HF, few Black patients are recognized as having the hereditary form of aTTR-related cardiomyopathy or undergo genetic testing for aTTR in routine clinical practice (37). Similarly, a recent multicenter series of 2,467 patients with hypertrophic cardiomyopathy demonstrated that Black patients were less likely than White patients to undergo genetic testing (38). The use of genetic ancestry in research and clinical medicine may help capture what portion of disease risk and drug response can be attributed to population-specific genetic variants (ie, TTR, APOL1, CYP2C19 polymorphisms, and so on), whereas race/ethnicity may be a better proxy for socioenvironmental exposures (39). Still, the application of precision medicine to race/ethnic groups with a disproportionate burden of disease is long overdue.
Provider and system-level challenges
Black patients are more likely to obtain care in the emergency department rather than ambulatory clinics, and Black and Hispanic patients are more likely to lack health insurance and access to outpatient care (40). Black and Hispanic patients have also been shown to have a higher risk of readmission after being discharged with a diagnosis of HF and fewer consultations with specialty providers (19,20). Although some investigators have suggested that racial/ethnic minority patients receive inferior HF care because they are more likely to receive care at underperforming hospitals, even within a hospital, minority patients are less likely to receive counseling measures (41). This disparity fits with reduced efforts to involve minority patients in health care decision-making, in general.
Within the health care system, there is persistent evidence of unequal treatment of Black and Hispanic patients with HF. Within emergency departments, Black patients with acute HF symptoms are less likely to be hospitalized than White patients with similar chief complaints (42). Upon admission to the hospital, Black and Hispanic patients are less likely to be admitted to a cardiology service, and Black patients with a primary diagnosis of acute HF requiring intensive care unit–level care are less likely to be seen by a cardiologist during their intensive care unit stay compared with White patients (25,43). Unequal access to CV specialty care may be an additional explanatory factor for why Black and Hispanic patients with HF are referred for advanced therapies later in their disease course and have higher INTERMACS scores at the time of MCS implantation as well as higher risk of transplant waitlist mortality (44).
Policy-level challenges
Inadequate access to health care has been recognized as having a disproportionate effect on the health of race/ethnic minorities. The Patient Protection and Affordable Care Act (ACA) sought to increase the overall percentage of Americans with health insurance, and has resulted in important gains by improving access to affordable health care and preventive services with proportionally greater gains for race/ethnic minorities. Recent analyses confirm states that expanded Medicaid under the ACA have had fewer deaths from CV causes than nonexpansion states, improved utilization of preventive therapies including antihypertensives and statins, and improved access to advanced HF therapies for Black patients (31,44-46). The Hospital Readmissions Reduction Program (HRRP), also a provision of the ACA, is one example of a value-based care model that uses financial penalties as the primary method to incentivize health care systems to “improve care quality” and reduce excess 30-day hospital readmissions. There is now evidence that value-based payment programs such as the HRRP disproportionately penalize safety-net hospitals that serve greater proportions of race/ethnic minorities and socioeconomically disadvantaged patients (47,48). These programs fail to take into account the systemic barriers that make optimal self-care more challenging for patients from disadvantaged backgrounds and more difficult for health care providers who provide care in chronically under-resourced settings. Ongoing efforts must seek to integrate socioeconomic and societal factors into the current risk adjustment algorithms to reverse trends that suggest minority-serving and safety-net hospitals are incurring excess payment penalties, which could actually worsen existing disparities.
CPG: The Landscape
HF represents the final common pathway for a multitude of CV disorders. Although not the panacea for resolving and addressing all of the points made in this document, CPG stem from a thorough review of the literature, and remain as the core of definitions, diagnosis, and treatment algorithms used to achieve optimal outcomes for patients of all races and ethnicities. Consequently, CPG tend to be as expansive as possible to address the common etiologies of HF. The current CPG coauthored by the American Heart Association/American College of Cardiology Foundation/Heart Failure Society of America was initially published in 2013, with focused updates in 2016 and 2017 (49). An update in 2022 is anticipated to incorporate the results of the most recent clinical trials. In the context of the intersection of HF with race/ethnicity, the only focused emphasis on specific treatment according to race/ethnicity in the CPG relates to H-ISDN use in NYHA functional class III-IV HFrEF patients and relative frequency of aTTR cardiac amyloidosis in Black patients.
Implementation Challenges
Black, Hispanic, and other populations of color are more likely than White individuals to be residents of socioeconomically disadvantaged communities served by safety net hospitals, where adoption and implementation of CPG may be suboptimal (50). Residents of impoverished communities with limited resources and limited socioeconomic means may struggle with keeping clinic appointments; transportation to appointments; and access to healthy food, health insurance, pharmacies, and ability to afford medications (43). These factors related to SDOH constitute a major obstacle for implementing CPG/guideline-directed medical therapy (GDMT) leading to suboptimal results and poor clinical outcomes (25). The rapidly evolving landscape for HF GDMT over the past 4 years has highlighted medication cost and affordability even in individuals with health insurance (38). Although CPG for primary prevention of CVD have urged clinicians to consider SDOH as a risk factor (51), CPG for HF has typically not included the SDOH and its impact on clinical outcomes.
A Necessary Future for the CPG
With increasing realization of the importance of SDOH, future updates in the HF CPG should provide practical strategies for mitigating disease in disadvantaged communities, coupled to metrics for optimal implementation of pharmacological and device therapy. Writing committees should acknowledge that significant changes in public policy are necessary to optimally reduce morbidity/mortality and eliminate health disparities. The perpetuation of entrenched structural and societal inequities provides the incubator for CVD risk factors to develop, fester, and eventually lead to chronic adverse CV outcomes, while simultaneously making it difficult to control these CVD risk factors or to effectively implement CPG. Therefore, while CPG place the focus on clinical treatment, they do not fully address the root causes of disease burden or provide the most optimal patient outcomes.
An additional focus of CPG should be acknowledging the lack of data within racial and ethnic groups caused by poor planning in recruitment for clinical trials and poor execution, despite lofty plans for enrolling diverse study populations. It is no longer acceptable to widely implement guidelines based on studies where our most vulnerable patients have not been included.
It is time for a paradigm shift in writing CPG that takes into account all relevant data with significant impact on HF incidence and prevalence, more accurately identifies the challenges in treatment, and provides comprehensive recommendations to address them. In addition to the medical treatment recommendations, CPG must highlight the need for rigorous public policies that will assist both patients and clinicians to prevent the uninhibited incubation of CVD risk factors in disadvantaged communities. For example, HTN is the leading preventable cause of HF, and is disproportionately prevalent in Black adults. HTN is exceedingly difficult to control in race/ethnic minorities, which may be, in part, caused by the stress of the lived experiences of Black patients, particularly those in impoverished environments (15,52).
Conclusions: Solutions
There are many systems of inequality that need to be addressed to confront disparities in HF care for racial/ethnic minorities. More work needs to be done to determine the impact of policy changes on health disparities, such as addressing food insecurities for low-income Black and Hispanic individuals and increasing prevalence of walkable neighborhoods. The broad effects of these long-standing and deepening inequities can feel insurmountable. However, many examples of interventions ranging from small to large scales have shown tangible and important improvements for patient care. For example, expansion of the Affordable Care Act Medicaid expansion resulted in increased heart transplant listings in Black patients (53). Addressing housing discrimination and income disparities are important strategies for reducing risk factors (54). These initiatives need to be tailored to the needs of the local and regional communities. Requisite implicit bias training should be considered for clinicians as one method to reduce disparities, albeit not the only effort, but coupled with commitment from leadership to eradicate racial and ethnic bias. Efforts should also enhance inclusivity of diverse racial and ethnic groups into medical education, postgraduate training, and beyond into the workforce. The benefits of a diverse health force cannot be overstated where diversity leads to benefits for all, including patients. Race concordant patient-provider relationships can improve the quality of communication experienced by patients and ultimately adherence (55). Pragmatic trial designs have allowed for real-world interventions that can quickly provide encouraging improvement rather than relying on rigid randomized trial designs that can be difficult to adapt to clinical practice. The use of a nontraditional health care setting (barbershops) significantly improved CV outcomes compared with traditional settings. In the realm of advanced HF, programs have demonstrated that race/ethnicity and sex-based disparities in MCS and transplant can be eliminated with comprehensive, specialized care (43). Other targets should be an unbiased, structured assessment of social support used to determine candidacy for advanced therapies.
As noted in the previous text, other programs, such as the HRRP, initially thought to benefit underserved patients by enhancing quality of care, improving coordination particularly at discharge, and reducing 30-day readmissions for HF may, in fact, disproportionately penalize safety-net hospitals that serve racial and ethnic minorities. There is mounting evidence that SDOH are in and of themselves a driver of 30-day readmissions (25). Risk-adjustment algorithms must take SES and societal factors into account to ensure that minority-serving and safety-net hospitals do not incur excessive payment penalties, as excess readmissions for these hospitals may also be influenced by aspects of the postdischarge environment that are beyond the control of the hospital or its providers. Ensuring that HF patients with acute events are admitted to appropriate services with cardiologists regardless of race/ethnicity may also improve outcomes. Standardized assessments of social factors (eg, nonadherence and emotional support) could reduce disparities (31). Race-based differences in who receives GDMT should be systematically measured. Finally, increasing workforce diversity, physical activity opportunities, and access to care through reduction of structural inequities may further improve outcomes (3).
A common theme that runs throughout this document and the proposed and diverse solutions should be of importance to each and every clinician caring for patients with HF by recognizing CV disparities within their own system of care. Clinicians must also assess the needs of their own practice and root out bias, whether explicit or implicit. Without these individual efforts, the goal of reaching equality of care for patients with HF appears very distant.
Funding Support and Author Disclosures
Dr Morris has received research funding from the National Institutes of Health/National Heart, Lung, and Blood Institute, AHRQ, the Woodruff Foundation, and the Association of Black Cardiologists. All other authors have reported that they have no relationships relevant to the contents of this paper.
Abbreviations and Acronyms
| CPG | clinical practice guidelines |
| CV | cardiovascular |
| CVD | cardiovascular disease |
| DM | diabetes mellitus |
| GDMT | guideline-directed medical therapy |
| HF | heart failure |
| HFrEF | heart failure with reduced ejection fraction |
| HRRP | hospital reduction readmission program |
| HTN | hypertension |
| MCS | mechanical circulatory support |
| SDOH | social determinants of health |
| SES | socioeconomic status |
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Footnotes
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