African American-Caucasian American differences in aortic valve replacement in patients with severe aortic stenosis

doi:10.1016/j.ahj.2021.01.005

American Heart Journal

Volume 234, April 2021, Pages 111-121

https://doi.org/10.1016/j.ahj.2021.01.005 Get rights and content

Background

Among patients with severe aortic stenosis (AS), there are limited data on aortic valve replacement (AVR), reasons for nonreceipt and mortality by race.

Methods

Utilizing the Duke Echocardiography Laboratory Database, we analyzed data from 110,711 patients who underwent echocardiography at Duke University Medical Center between 1999 and 2013. We identified 1,111 patients with severe AS who met ≥1 of 3 criteria for AVR: ejection fraction ≤50%, diagnosis of heart failure, or need for coronary artery bypass surgery. Logistic regression models were used to assess the association between race, AVR and 1-year mortality. χ2 testing was used to assess potential racial differences in reasons for AVR nonreceipt.

Results

Among the 1,111 patients (143 AA and 968 CA) eligible for AVR, AA were more often women, had more diabetes, renal insufficiency, aortic regurgitation and left ventricular hypertrophy. CA were more often smokers, had more ischemic heart disease, hyperlipidemia and higher median income levels. There were no racial differences in surgical risk utilizing logistic euroSCORES. Relative to CA, AA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) yet similar 1-year mortality (aHR 0.81, 95% CI 0.57-1.17, P = .262). There were no significant differences in reasons for AVR nonreceipt.

Conclusions

We identified 143 African Americans (AA) and 968 Caucasian Americans(CA) with severe AS who met prespecified criteria for AVR.. AA relative to CA were more often women, had more diabetes, renal insufficiency, and left ventricular hypertrophy, however had less tobacco use, ischemic heart disease, hyperlipidemia and lower median income levels. Among patients with severe AS, AA relative to CA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) without significant differences in reasons for AVR nonreceipt and similar 1-year mortality.

Section snippets

Data capture and study population

Adult patients (age >18 years) were identified from the Duke Echocardiography Laboratory Database (DELD) (1999-2013). Details of the DELD have been previously described and will be briefly summarized.¹⁴ The DELD includes a digital archive of all echocardiograms performed at Duke University Hospital and its satellite clinics. The database has been prospectively maintained from 1995 to 2015 and includes clinical information drawn from a variety of sources. Follow-up information for DELD patients

Baseline characteristics

We identified 1,848 of 110,711 (1.6%) patients within the DELD database with severe AS of which 236 of 1,848 (12.8%) were AA and 1,612 of 1,848 (87.2%) were CA. Among patients with severe AS, 1,111 met prespecified criteria for AVR (143 AA and 968 CA) (Figure 1). AA individuals were more often female (66.4% vs 43.1%, P < .001), had lower median household incomes ($38,529 vs $47,600, P < .001), were more likely to have diabetes (45.5% vs 31.4%, P < .001), hypertension (84.6% vs 75.7%, P = .019),

Discussion

In contrast with prior studies that have assessed AVR utilization and mortality by race we additionally determined reasons for AVR nonreceipt. Moreover, outside of large registries such as the National Cardiovascular Data Registry or Transcatheter Valve Therapy, our paper has one of the largest patient populations to assess racial differences in the treatment, and outcomes of patients with severe AS.

Our analysis was notable for several findings. Despite a higher proportion of risk factors

Study limitations

The findings of this study must be interpreted in the context of its limitations. This analysis involved a single center retrospective cohort with specific practice patterns, thus limiting generalizability. Procedures performed at outside hospitals were not captured, potentially leading to underreporting. Data was unavailable to report the rates of patients receiving CABG and AVR within the same surgery. However, we noted that Caucasian Americans were more likely than AA to have the need for

Conclusions

Despite a higher proportion of traditional risk factors, AA relative to CA had lower prevalence of severe AS. Among patients with severe AS eligible for AVR, AA patients were less likely to undergo AVR within 1-year. AS reclassification and patient refusal were the biggest drivers of AVR nonreceipt for AAs, whereas high operative risk and death prior to procedure were the biggest drivers for CAs. Despite these differences, there was no significant racial difference in 1-year all-cause

Funding

Support provided by the Duke Center for Research to Advance Health care Equity (REACH Equity), which is supported by the National Institute on Minority Health and Health Disparities under award number U54MD012530.

Conflict of interest

The authors whose names are listed above certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript.