Social Determinants of Health in Non Valvular Atrial Fibrillation NVAF.pptx

Addressing Social Determinants of Health in NVAF

1. The Biggest Risk to Cardiovascular Health: Addressing Social Determinants of Health in NVAF

2. Patient Case 56-yr-old Black female with uncontrolled HTN, type 2 diabetes BMI 38 kg/m 2 Noted to have palpitations and weakness on recent exam ECG showed AF Patient started on warfarin but had wide variations in INR Patient given prescription for rivaroxaban, but it wasn’t covered by insurance and never filled

3. Atrial F ibrillation : M ost C ommon C ardiac A rrhythmia Nearly 60 million adults worldwide in 2019 and substantial social/medical burdens AF associated with: Multiple CV and non-CV outcomes HF MI Ischemic stroke and death Frailty Cognitive decline High healthcare utilization Social determinants of health contribute to recognition, evaluation, treatment, outcomes of diverse disease states but limited examination in AF Kornej . Circ Res. 2020; 127:4. Roth . J Am Cardiol. 2020;76:2982. Lippi . Int J Stroke. 2021; 16:217.

4. Race and E thnicity Influences of pervasive racial bias and discrimination within and beyond medical care Racial inequities in health/healthcare are widely described across CV conditions, including AF Despite availability of studies addressing disparities, in US, death rate from CV disease is 20% higher in Black vs White Americans Race and ethnicity may influence AF recognition to clinical evaluation, management, short-term and long-term outcomes Essien . JAMA Cardiol. 2018;3:1174. Essien . J Natl Med Assoc. 2020;112:103. Smedley. Unequal treatment: confronting racial and ethnic disparities in health care. National Academies Press, 2003. Jones . Ethn Dis. 2018;28:231. Magnani . JAMA Cardiol. 2016;1:433. Nanda . Curr Treat Options Cardiovasc Med. 2019;21:85 . Ugowe . Heart Rhythm. 2018;15:1337. Van Dyke . MMWR Surveill Summ. 2018;67:1. Williams. Behav Med. 2009;32:20. Williams . JAMA. 2020; 323:2478.

5. Race, E thnicity, and AF I ncidence Despite preponderance of clinical risk factors in AF: HTN, DM, obstructive sleep apnea, obesity, in individuals from underrepresented racial and ethnic groups in US Multiple analyses show lower rates of AF in Black, Hispanic or Latino (further referred to as Hispanic), Asian, Native vs White Americans ARIC study: biracial, community-based >15,000 participants conducted in 4 US cities Lifetime risk developing AF over 25 yr: ~33% White vs ~20% Black Americans Dewland . Circulation. 2013; 128:2470. Linares . Heart Rhythm. 2019;16:686; Mou . Circ Arrhythmia Electrophysiol. 2018; 11:e006350 . Sanchez . Circulation. 2019; 140:1605. Staerk . Circ Res. 2017; 120:1501.

6. Dewland TA et al. Circulation. 128, 2470–2477 (2013). Number of Incident AF Diagnoses 50,000 100,000 150,000 200,000 250,000 Ambulatory Surgery n=27,140 Emergency Department n=52,952 Inpatient Hospitalization n=295,226 Whites Non-Whites Primary Diagnosis* Incident AF Diagnoses by Race/Ethnicity

7. Rodriguez CJ et al. Ann. Epidemiol 25, 71–76 (2015). Incidence Rates per 1,000 person-years Non-Hispanic White Chinese Non-Hispanic Black Hispanic 5 10 15 20 25 30 45-64 65-74 75-84 Racial/Ethnic Differences in AF Incidence and Risk Factors

8. AF Prevalence Higher prevalence of AF risk factors in racial/ethnic groups Underrepresented in clinical literature: Black, Hispanic, American Indian/Alaska Native individuals Decreased observed prevalence of AF vs White Americans in US termed “ paradox” Social factors as driver of differences REGARDS study: US observational >30,000 Black and White Americans Black participant awareness of having AF 1/3 that of White participants (OR: 0.32; 95% CI: 0.20-0.52) Christensen . Heart Rhythm. 2017;14:1856. Meschia . Stroke. 2010; 41:581. Soliman . Future Cardiol. 2009;5:547.

9. AF Incidence Across Racial/Ethnic Groups MESA study (2020): similar rates of AF incidence across all racial/ethnic groups 14-day ambulatory continuous rhythm monitoring detect AF instead of clinical detection AF differential clinical recognition by providers partly explains racial/ethnic differences in AF incidence vs true biologic or genetic differences between racial/ethnic groups Heckbert . Circ Arrhythm Electrophysiol. 2020; 13:e007698.

10. Race/Ethnicity and AF Outcomes Underdiagnosis of AF and lower receipt of guideline-based therapies  differences in AF outcomes by race/ethnicity Blacks with AF have higher rates ischemic stroke and CV morbidity (MI, HF) vs White patients ARIC Study: Black adults with AF have 2x incidence rates vs White participants Stroke (21.4 vs 10.2 per 1000 person-yr; P < .01) Death (106.0 vs 55.9 per 1000 person-yr; P < .01) Birman-Deych. Stroke. 2006;37:1070. Buchmueller. Am J Public Health. 2016;106:1416. Essien. Gen Intern Med. 2019;34:484. Johnson. J Am Coll Cardiol. 2017;69:906. Kabra. J Am Coll Cardiol. 2016;68:461. Magnani. JAMA Cardiol. 2016;1:433. O’Neal. PLoS ONE. 2019;14:e0222147. Pool. Epidemiology. 2018;29:207. Ugowe. Heart Rhythm. 2018;15:1337.

11. ARIC Study: Racial Differences in AF-Related CVD and Mortality Rate Differences Outcomes Stroke, HF, Coronary Heart Disease (CHD), and Mortality Stratified by White and Black Race in Atherosclerosis Risk in Communities Study. Rate difference Black exceeds White individuals with AF across the 4 outcomes. Error bars = 95% CIs. Figure Legend: JAMA Cardiol . 2016;1(4):433-441. doi:10.1001/jamacardio.2016.1025 Rate Difference Rate Difference Rate Difference Rate Difference Stroke Heart Failure CHD All-Cause Mortality 35 30 25 20 15 10 5 White Race Black Race 20 40 60 80 100 120 140 160 180 White Race Black Race 10 20 30 40 50 60 White Race Black Race 20 40 60 80 100 120 140 White Race Black Race

12. Race/Ethnicity and AF Outcomes Cohort study to assess efficacy of warfarin treatment in patients with AF Disparities in stroke risk, mortality of Hispanic Americans with AF-national US registry (N = 23,657) Rate of stroke cases per 100 person-yr 5.2 (95% CI: 4.6-5.8) for White Americans 12.2 (95% CI: 8.0-18.5) for Black Americans 10.6 (95% CI: 6.0-18.7) for Hispanic Americans Birman-Deych. Stroke. 2006;37:1070.

13. Possible Explanations of AF Paradox Limited ascertainment due to structural racism; decreased access to health care among racial/ethnic groups underrepresented in medicine Higher incidence and prevalence of AF in White vs individuals of other races/ethnicities in the US Varying rates of premature death by race/ethnicity  differential exposure to AF-related risk factors and incidence AF, associated with old age Traditional clinical risk factors for AF (ie, HTN, DM, obesity) more common in racial/ethnic groups under-represented in medicine Christensen . Heart Rhythm. 2017;14:1856. Heckbert . Circ Arrhythm Electrophysiol. 2020; 13:e007698 . Meschia . Stroke. 2010; 41:581 .