Why do we ignore guidelines for some patients in treating heart failure?
Key Takeaways
There are significant disparities in the treatment of heart failure, particularly among women and minority groups, despite the availability of proven therapies.
Women are less likely to receive guideline-directed care for heart failure, including diagnostic testing and interventions, compared with men.
Racial and ethnic minority groups, such as Black and Hispanic patients, are at higher risk for developing heart failure at a younger age, have higher hospitalization rates, and face implicit biases that may limit their access to advanced therapies.
Disparities in treatment of heart failure, both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), persist among female patients and patients from minority and underrepresented groups, in spite of the availability of advanced and well-proven therapies.
Glass ceiling for heart failure treatment
Heart failure is a major cause of morbidity and mortality in women, particularly in older women. Women are more likely to have HFpEF, yet women are generally underrepresented in clinical trials of heart failure interventions. Furthermore, management of heart failure has been shown to differ by sex.
In a global analysis of treatment and outcomes in heart failure, involving 18,553 patients hospitalized with acute heart failure, researchers found that women were less likely than men to be referred for testing or to receive guideline-directed care.[]
Dr. Tamari Miller and colleagues, in their review of racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure, found that women receive fewer interventions for cardiogenic shock following acute MI.[]
They also noted that “Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies.”
"These disparities are minimized when therapies are properly utilized and patients are treated according to guidelines."
— Authors, Current Opinion in Cardiology
Disparities span racial and ethnic groups
A 2022 position statement from the Heart Failure Society of America (HFSA) noted, “Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern.”[]
The HFSA statement points out that disparities “span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from stage A to stage D.”
There is a higher risk for the development of HF among patients who are members of racial or ethnic minority groups, primarily related to a higher prevalence of cardiovascular risk factors like hypertension, diabetes, and obesity among minority populations. Black and Hispanic patients, the statement notes, develop heart failure at a younger age, are more likely to be underinsured, and have higher heart failure hospitalization rates, as compared with non-Hispanic White patients.
The rate of heart failure-related hospitalization for Black men and women is nearly 2.5 times that for White patients, and mortality rates are also higher—this disparity is even more pronounced among younger adults with heart failure (35 to 64 years of age).[]
The HFSA notes that this finding is “particularly alarming,” given that “younger patients should theoretically be evaluated more often for advanced HF therapies, including [heart transplantation] and left ventricular assist devices, given the greater likelihood of extending duration of life.”
Potential solutions
A combination of multi-level changes must be implemented to achieve change and eliminate the striking disparities in heart failure treatment, and will need to include policy-, healthcare system-, community-, organization-, and individual-level elements. According to the HFSA, “systems that have historically permitted disadvantaged populations to exist with inferior access to health care must be critically evaluated, dismantled, and restructured to improve care models.”
Raising awareness among cardiologists and heart failure clinicians of implicit, often unrecognized, bias that may influence treatment decisions is also important for facilitating change and improving the delivery of guideline-directed medical care for all patients with heart failure, regardless of background.
What this means for you
To address the disparities that exist in the treatment of heart failure, it is essential for cardiologists work actively toward ameliorating them. Apply guideline recommendations for the treatment of heart failure equally, regardless of race, ethnicity, or sex, and consider advanced therapies and interventions for all who are eligible. This eligibility should be based on patient presentation and clinical characteristics as well as heart failure stage. By implementing multi-level changes at the policy, healthcare system, community, organizational, and individual levels, we can strive to eliminate these striking disparities and provide equitable care to all heart failure patients.