Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation

doi:10.1016/j.hrthm.2021.02.008

Heart Rhythm

Volume 18, Issue 6, June 2021, Pages 987-994

https://doi.org/10.1016/j.hrthm.2021.02.008 Get rights and content

Background

Select patients with atrial fibrillation and contraindication to anticoagulation may benefit from percutaneous left atrial appendage closure (pLAAC).

Objective

The purpose of this study was to evaluate racial disparities in the nationwide utilization and outcomes of pLAAC.

Methods

We identified 16,830 hospitalizations for pLAAC between 2015 and 2017 using the National Inpatient Sample. Baseline characteristics, in-hospital mortality, complications, length of stay, and discharge disposition were assessed between White and Black/African American (AA) populations.

Results

Black/AA patients represented 4.1% of nationwide pLAAC recipients and were younger, more likely to be female, and had greater prevalence of hypertension, heart failure, hyperlipidemia, obesity, chronic kidney disease, and prior stroke history (P <.001 for all). Black/AA patients had significantly increased length of stay and nonroutine discharge (P <.001 for both) but comparable in-hospital mortality to White patients. Black/AA patients suffered from greater postoperative stroke (0.7% vs 0.2%), acute kidney injury (4.5% vs 2.1%), bleeding requiring transfusion (4.5% vs 1.4%), and venous thromboembolism (0.7% vs 0.1%; P <.01 for all). After controlling for possible confounding factors, Black/AA race was independently associated with significantly increased odds of bleeding requiring blood transfusion, stroke, venous thromboembolism, and nonroutine discharge.

Conclusion

Among pLAAC recipients nationwide, Black/AA populations were underrepresented and had greater complication rates, length of stay, and discharge complexity. This study highlights the importance of addressing ongoing racial disparities in both utilization and outcomes of pLAAC.

Introduction

Patients with atrial fibrillation (AF) have significantly increased risk of thromboembolic events, such as transient ischemic attacks or cerebrovascular accidents, and frequently require anticoagulation based on the CHA₂DS₂-VASc scoring system, with a score ≥2 in men or ≥3 in women warranting oral anticoagulation to mitigate such risks.¹ However, patients with known thrombocytopenia or bleeding disorders, recurrent gastrointestinal bleeding, prior severe bleeding, poor adherence to anticoagulant therapy, or high risk of falling may not be candidates for long-term anticoagulation. Percutaneous left atrial appendage closure (pLAAC) has grown increasingly attractive as an alternative for patients with nonvalvular AF and contraindications to long-term anticoagulation, and was updated to a class IIb Indication in the 2019 American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines.¹

In the PROTECT-AF (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial, pLAAC met criteria for superiority compared to warfarin therapy in preventing stroke, systemic embolism, and cardiovascular death.² In the PREVAIL (Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy) trial, pLAAC was shown to be noninferior to warfarin for ischemic stroke prevention at least 7 days after the procedure.³ A meta-analysis of these 2 major studies showed that pLAAC led to decreased hemorrhagic strokes, cardiovascular or all-cause mortality, and bleeding compared to warfarin.⁴ The WATCHMAN device (Boston Scientific Corporation, St Paul, MN) became the first endocardial device for pLAAC approved by the Food and Drug Administration (FDA) in March 2015.³^,⁵ Continued access to both the PROTECT-AF and PREVAIL trials, with 5-year follow-up, has supported continued reduction in hemorrhagic and total stroke rates relative to prediction by CHA₂DS₂-VASc score.⁶ In light of these promising studies, the volume of pLAAC performed nationwide has greatly increased annually between 2015 and 2017, while in-hospital complications and mortality have decreased.⁷ However, little is known regarding the potential racial disparities in both the utilization and in-hospital outcomes of pLAAC among Black/African American (AA) compared to White populations. For this reason, we sought to evaluate in-hospital outcomes for pLAAC between 2015 and 2017, using the most recently available data following FDA approval of the WATCHMAN device.

Section snippets

Data source

The National Inpatient Sample (NIS) offers the largest publicly available all-payer database of hospitalizations, representing a 20% random, stratified sample of hospital discharges in the United States.⁸ International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic and procedural codes were used to identify the study population (Supplemental Table 1). Institutional review board approval was not needed, as all patient information was de-identified.

Baseline characteristics

Among a total of 16,830 hospitalizations for pLAAC, only 685 patients (4.1%) identified as Black/AA compared to 14,435 (85.8%) as White. Black/AA patients were significantly younger (70.1 ± 10.5 years vs 76.0 ± 7.8 years; P <.001) and more frequently female (50.0% vs 39.3%; P <.001) (Table 1). Black/AA patients were less frequently admitted electively (82.1% vs 90.5%; P <.001). Black/AA patients had trend of increased CHA₂DS₂VASC score ≥2 (96.3% vs 94.4%; P = .04). Black/AA patients had higher

Discussion

In this study, we report 2 major findings. First, Black/AA populations were largely underrepresented among nationwide pLAAC performed between 2015 and 2017. Second, Black/AA populations had increased postprocedural complications, length of stay, and discharge complexity.

First, Black/AA populations represented 4.1% of all pLAAC recipients nationwide between 2015 and 2017 compared to White populations representing nearly 86%, this despite potentially increased eligibility, with higher prevalence

Conclusion

Significant racial disparities exist in both the utilization and in-hospital outcomes of percutaneous left atrial appendage closures in Black/AA compared to White populations. Between 2015 and 2017, Black/AA patients represented only 4.1% of nationwide pLAAC recipients. Black/AA populations had comparable in-hospital mortality but significantly increased length of stay and nonroutine discharge. After adjusting for comorbidities and possible confounding factors, Black/AA race was independently

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Racial and ethnic disparities in the access to left atrial appendage occlusion (LAAO) have been previously described. However, it remains unclear if there have been any changes in these disparities over the years and if the disparities include other racial and ethnic groups not previously studied. We aimed to determine the temporal evolution of the racial and ethnic disparities in the utilization of LAAO from 2016 to 2019. We conducted a retrospective cohort study using the National Inpatient Sample from 2016 to 2019. International Classification of Diseases, 10th edition codes were used to identify all adult admissions with atrial fibrillation (AF) and those who underwent LAAO. The sample was divided into Asian American and Pacific Islander, Black, Hispanic, White, and other races/ethnicities. Our primary outcome was the utilization of LAAO in patients admitted with a diagnosis of AF. The Cochran-Armitage test was conducted to evaluate the yearly trend in LAAO utilization stratified by race/ethnicity. Multivariable regression analysis was conducted to assess the association of race/ethnicity with multiple end points. A total of 59,415 patients underwent LAAO. The highest yearly increase in LAAO utilization was seen in White patients (trend: 0.16%, p <0.001). Furthermore, compared with White patients, the yearly increase in LAAO utilization was lower in all other racial/ethnic groups. Black patients had the lowest odds of who underwent LAAO (odds ratio = 0.45, 95% confidence interval 0.40 to 0.50, p <0.001). In conclusion, significant gaps exist in the utilization of LAAO between racial and ethnic groups, and they appear to continue worsening from 2016 to 2019.
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Atrial fibrillation (AF) is the most common clinical arrhythmia, and it results in adverse outcomes and increased healthcare costs. Racial and ethnic differences in AF management, although recognized, are poorly understood. This review summarizes racial differences in AF epidemiology, genetics, clinical presentation, and management. In addition, it highlights the underrepresentation of racial and ethnic populations in AF clinical trials, especially trials focused on stroke prevention. Specific strategies are proposed for future research and initiatives that have potential to eliminate racial and ethnic differences in the care of patients with AF. Addressing racial and ethnic disparities in healthcare access, enrollment in clinical trials, resource allocation, prevention, and management will likely narrow the gaps in the care and outcomes of racial and ethnic minorities suffering from AF.
La fibrillation auriculaire (FA) est la forme clinique d’arythmie la plus fréquente, et elle entraîne des résultats défavorables ainsi qu’une augmentation du coût des soins de santé. Les différences liées à la race et à l’origine ethnique qui existent dans la prise en charge de la FA, bien que reconnues, sont mal comprises. Le présent article de synthèse résume les différences liées à la race observées sur le plan de l’épidémiologie, de la génétique, du tableau clinique et de la prise en charge de la FA. En outre, il met en lumière la sous-représentation de groupes raciaux et ethniques dans les études cliniques sur la FA, en particulier celles axées sur la prévention des accidents vasculaires cérébraux. Des stratégies ad hoc sont proposées pour que la recherche et les initiatives futures favorisent l’éradication des différences liées à la race et à l’origine ethnique dans les soins prodigués aux patients atteints de FA. Le fait de s’attaquer aux disparités liées à la race et à l’origine ethnique qui touchent l’accès aux soins de santé, l’inscription aux essais cliniques, l’allocation des ressources, la prévention et la prise en charge des patients permettra probablement de réduire les lacunes en matière de soins et de résultats chez les personnes atteintes de FA issues de minorités raciales et ethniques.

View all citing articles on Scopus

: Funding sources: The authors have no funding sources to disclose.

: Disclosures: The authors have no conflicts of interest to disclose.

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Published by Elsevier Inc. on behalf of Heart Rhythm Society.

ClinicalOutcomesRacial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Data source

Baseline characteristics

Discussion

Conclusion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Int J Surg

Heart Rhythm

J Natl Med Assoc

Heart Rhythm

Heart Rhythm

Am J Cardiol

Am Heart J

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States

J Cardiovasc Electrophysiol

Clinical
Outcomes
Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation