Heart Failure with Reduced Ejection Fraction And COVID-19, When The Sick Get Sicker: Unmasking Racial and Ethnic Inequities During A Pandemic

Abstract:

Minoritized racial and ethnic groups have the highest incidence, prevalence, and hospitalization rate for heart failure. Despite improvement in medical therapies and overall survival, the morbidity and mortality of these groups remain elevated. The reasons for this disparity are multifactorial, including social determinant of health (SDOH) such as access to care, bias and structural racism. These same factors contributed to higher rates of COVID-19 infection among minoritized racial and ethnic groups. In this review, we aim to explore the lessons learned from the COVID 19 pandemic and its interconnection between heart failure and SDOH. The pandemic presents a window of opportunity for achieving greater equity in the health care of all vulnerable populations.

Key Points

• •The COVID-19 pandemic illustrated the important relationship between social determinants of health and heart failure outcomes among minoritized racial and ethnic communities.
• •Healthcare accessibility is a major challenge for minoritized racial and ethnic groups. These challenges are further exacerbated by policies that fail to address social determinants of health.
• •Supporting studies that engage community based participatory research and implementation science may lead to equity in heart failure care among minoritized racial and ethnic groups.

Introduction

Healthcare disparities are greatest for minoritized racial and ethnic groups and have worsened with the COVID-19 pandemic.¹ In 2020, Black patients were overrepresented in COVID-19 death statistics, with twice the expected total of deaths based on population size.² Black and Hispanic populations had a reduced life expectancy in 2021 and 2022 compared to White patients, related to COVID-19.³ Moreover, American Indian populations experienced a decrease in life expectancy due to the COVID-19 pandemic.⁴

Similarly, risks of developing heart failure (HF) are greater in some minoritized racial and ethnic groups. Disparities in treatment and recognition of precursors of HF may contribute to differences in HF presentation by race and ethnicity.⁵ Hypertension is one of the main etiologies of HF and remains worse treated to control among Black and Mexican patients compared to White patients.⁶ Black individuals have the highest prevalence of HF at 3.6%⁷ and more than twice the risk of developing HF before the age of 65 compared to White women and men.⁸ Latino/a/x and White men and women have similar prevalence of HF.⁷ However, abnormal left ventricular structure and function have been observed at younger ages in Latino/a/x individuals than White individuals.^{7 , 9 , 10} Due to underreporting, there is limited information on the prevalence of HF in the American Indian population.^{7 , 11 , 12} In addition, minoritized racial and ethnic groups are less likely to be prescribed guideline-directed medical therapy (GDMT) and nonpharmacological therapies.^{5 , 13}

COVID-19 influenced outcomes for patients with HF. Hospitalizations for HF with reduced ejection fraction (HFrEF) are often associated with increased mortality.¹⁴ However, attempts to reduce hospitalizations does not necessarily equate reduced mortality. Multiple studies of the U.S. healthcare policy have demonstrated that attempting to reduce needed hospitalizations results in higher mortality.¹⁵ Similarly, during the initial years of the COVID-19 pandemic, HF hospitalizations decreased inappropriately.¹⁶ Data suggests that patients delayed and forwent hospital care out of concern for increased risk of COVID-19 in waiting rooms and in over-populated areas.¹⁷ The full ramifications of delayed care and treatment are still forthcoming. In this review, we describe the interplay between HF, COVID-19, and outcomes for minoritized racial and ethnic groups, and propose strategies to improve access for these patients.

COVID-19 Unmasking Health Care Disparities

COVID-19 disproportionately affected minoritized racial and ethnic communities and lower resourced communities.^{3 , 18 , 19} COVID-19 was declared a global public health emergency on March 11, 2020, by the World Health Organization (WHO) ²⁰, and had catastrophic consequences since that time. Between March 1, 2020 and January 2, 2021 the excess death rate was higher among non-Hispanic Black populations (208.4 deaths per 100,000) than non-Hispanic White or Hispanic/ Latinx populations (157.0 and 139.8 deaths per 100,000, respectively). ³ The COVID-19 pandemic unmasked significant differences in healthcare delivery.²¹

COVID-19 highlighted how intricately race, ethnicity, gender, and socioeconomic position impact the overall health of individuals and the community.^{22 , 23} Vaccine hesitancy was simplistically mislabeled as a blanket reason for low initial receipt of COVID-19 vaccine among minoritized racial and ethnic populations and populations with lower socioeconomic resources. National work led by Dr. Boyd and others helped identify how systemic racism contributed to low receipt of COVID-19.²⁴ Major issues included an untrustworthy medical system and unequitable access to care.^{18 , 19} Patients were unsure of effectiveness of vaccines in their population groups. Misinformation was prevalent. Patients were disadvantaged for lack of broadband internet, lack of knowledge of how to sign-up on electronic schedules that were frequently full, lack of primary care health professional relationships, lack of readily available transportation, lack of flexible jobs allowing sick days/days to visit healthcare professionals, and lack of funds to support childcare and or/ travel for appointments.²⁵ A disproportionate amount of these burdens were upon minoritized racial and ethnic groups and women.

The pandemic furthered conversations relating to social determinants of health (SDOH). SDOH include education access and quality, healthcare and quality, neighborhood and built environment, social and community context, and economic stability. ²⁶ SDOH are now recognized as being responsible for 50% or more of healthcare outcomes, higher than attribution for health behaviors.²⁷ The confluence of SDOH with COVID-19 resulted in communities being overburdened with disease and worse outcomes.²⁸ During the pandemic the social ills of society took center stage in the media. Many became aware of the importance of addressing SDOH to improve health outcomes beyond COVID-19, such as HF.

SDOH greatly impacted HF outcomes among minoritized racial and ethnic groups. ⁵ Education is associated with health literacy among patients with HF; ²⁹health literacy is associated with worse outcomes among patients with HF. ³⁰Due to redlining and structural racism, minoritized racial and ethnic groups have systematically worse access to good schools, financial and social support systems to obtain college education.31, 32, 33 For years, healthcare access and quality have been robustly detailed as inequitable for minoritized racial and ethnic groups compared to White populations. ^{34 , 35} Despite deriving similar benefits from guideline directed therapy, African American patients are less likely than White patients to receive cardiac resynchronization therapy (CRT)^{36 , 37}. African American, Hispanic and Asian patients receive fewer physician referrals for cardiac exercise training and lower participation in cardiac rehabilitation than White patients.38, 39, 40 A similar trend can also be seen in other therapies such as VAD, transplants and percutaneous mitral valve repair (TMVr).⁵ Access to insurance has helped improve some disparities among patients with HF such as heart transplants⁴¹, but many remain in respect to access to other devices and therapies.42, 43, 44, 45 Related to redlining, neighborhood deprivation is associated with 12% increase in incident HF, ⁴⁶and food deserts are associated with increased HF risk, which are more prevalent among minoritized racial and ethnic communities. SDOH must be addressed to reduce racial and ethnic HF disparities⁴⁷.

Pathophysiology Between HF and COVID-19

Although the social context may be the most important for understanding racial and ethnic disparities in HF in relation to COVID-19, it is also important to contextualize how COVID-19 contributes to HF across racial and ethnic groups. COVID-19 can cause direct and indirect cardiomyocyte damage leading to HF. COVID-19 infection causes endothelial cell activation and dysfunction in macro and microcirculation resulting in thrombi formation and organ injury. Endotheliopathy causes vasoconstriction and vascular injury triggering thrombus formation from platelet hyperreactivity.⁴⁸ About 25-50% autopsy specimens have demonstrated presence of the virus in subendothelium and pericytes.⁴⁹ Hypoxemia from respiratory infection, along with increased oxygen demand causes stress and weakening of cardiomyocytes.

The acute phase of severe COVID infection is associated with release of pro-inflammatory cytokines like interleukins, tumor necrosis factors, interferons. This attracts inflammatory cells and the dysregulated immune system causes cytotoxicity and organ damage.⁵⁰ Cardiac biomarkers like troponin are usually elevated and portends worse prognosis. Cardiomyocytes have increased expression of angiotensin converting enzyme 2 receptors. The virus attaches to these receptors to gain entry to the tissue. Imaging studies have shown myocardial inflammation even in asymptomatic patients.⁵¹ Myocarditis from COVID-19 could be from direct invasion or from the heightened immune response. In addition, stress cardiomyopathy has been increasingly seen with COVID-19 infection with reported incidence of about 7% during the early part of the pandemic.⁵² Right HF alone can be seen in patients with severe pulmonary involvement or in patients with acute large pulmonary embolism. Diastolic HF physiology can be a sequel of COVID infection or could be from progression of subclinical dysfunction from inflammation, fibrosis, and myocardial cell injury.

Relationship between HF and COVID-19 Outcomes

HF in itself is also associated with poor outcomes with COVID-19 infection including an increase in mortality, intensive care utilization and severity of infection. In a large database analysis of >90,000 patients with diagnosis of COVID-19, history of HF was associated with increased mortality. In chronic stable HF, patients 30-day and 90-day mortality was 8.0% and 9.0% respectively, and patients with worsening HF had highest mortality of 15.6% and 16.5%.⁵³ Another study reported 1 in 3 in patients with HFrEF died and attributed this high rate of mortality to comorbid conditions and sociodemographic position.⁵⁴ Patients recovered from COVID-19 hospitalization with no prior history of HF are also at increased risk of developing de novo HF. In the national cohort COVID collaborative study, authors noted a 45% higher hazard of incident HF.⁵⁵ Although the exact etiology of this association is not clear, shared pathophysiology is thought to be the cause.

COVID-19 was associated with reduction in HF hospitalizations. A retrospective study of an urban hospital in northern Philadelphia revealed a 10% decrease after the start of the COVID pandemic, in a period comprising January 2019 to November 2020 ⁵⁶. Similar findings were observed in a large medical center in Mississippi, where HF hospitalizations declined by 50% after the first diagnosed case in the state, with a further decline after that date ⁵⁷. Furthermore, a nationwide study in United Kingdom saw a 46% decline in HF hospitalization post-pandemic when compared to pre-pandemic data, and this was accompanied by increased community mortality ⁵⁸.

Multiple theories have been proposed to explain the decline in HF hospitalizations. This decrease in hospitalizations has been attributed to a decreased rate of presentation to the hospital secondary to patient’s fears of contracting COVID-19 while receiving medical care during the pandemic ⁵⁷. In addition, the volume of COVID-19 cases overwhelmed the healthcare system and is thought to have led to decreased ability to deal with non-COVID related conditions, including certain cardiovascular conditions such as HF ⁵⁹.

Increased cardiovascular mortality associated with COVID-19 were notably more common among minoritized racial and ethnic groups ⁶⁰. A U.S. National Center for Health Statistics study revealed that Black, Hispanic and Asian populations each experienced an approximate 20% increase in heart disease deaths, compared to 2% for non-Hispanic White populations from March to August 2020, compared to the same months in 2019⁶⁰. While the COVID-19 pandemic was associated with an increased cardiovascular disease mortality in all ethnic groups, another retrospective nationwide study in the US revealed that Black individuals had 3-fold higher rates of excess CVD mortality (13.8%) compared to White individuals (5.1%) ⁶¹. Excess mortality due to HF was also higher in Black individuals, with a 9.1% increase in 2020 compared to a 0% increase in White individuals.

Relationship Between HF disparities and Access to Care

Inadequate access to care remains a key contributor to higher rates of death with COVID-19 and HF for minoritized racial and ethnic groups. Pre-existing problems in U.S. healthcare delivery were worsened during the pandemic when access to healthcare professionals was limited to emergencies.⁶² Factors such as clinical inertia, cost of care, lack of insurance or underinsurance, clinician bias and structural racism disproportionately limit access to care for minoritized patients and can worsen during a pandemic.^{13 , 35} Low prescribing patterns of HF GDMT exist overall but under prescription of HF GDMT therapy is worse in Black patients who have a higher HF disease burden than other populations.^{13 , 63 , 64} For multiple centers, telemedicine did not facilitate major changes in GDMT prescribing patterns during the pandemic and in some cases resulted in lower prescribing of GDMT.^{65 , 66} While this is variable across centers, it is important to recognized that telemedicine may not benefit under resourced communities substantially if barriers to broadband internet are not also addressed⁶⁷, which disproportionately impacts minoritized racial and ethnic groups.

Inadequate insurance is an established barrier to HF care and a SDOH. U.S. healthcare policies which expanded access to healthcare insurance such as the Affordable Care Act (ACA) Medicaid Expansion have been associated with increased prescribing of one form of HF GDMT in Hispanic patients, ⁴² increased listing for heart transplant among Black patients, ⁴¹but has not increased delivery rates across minoritized racial and ethnic groups to proportionate levels of disease prevalence. Furthermore, this policy was not associated with improvement in delivery of cardiac resynchronization therapies⁴⁴, nor ventricular assist devices (VAD)⁴³ across racial and ethnic groups. This does not negate the importance of adequate insurance but stresses the need for insurance that is broadly accepted, appropriately reimbursed, and not associated with additional biased care.

Clinician bias and structural racism are associated with reduced access to HF care for minoritized racial and ethnic groups. In both national and single center studies, Black patients have been less likely than White patients to receive care by a cardiologist when admitted for HF.^{68 , 69} Black patients have consistently been less likely to receive advanced HF therapies than White patients in national databanks and multi-center studies.^{70 , 71} A national study of heart failure healthcare professionals randomized to two patient vignettes differing only by race demonstrated that Black race was associated with lower likelihood of allocating a patient to heart transplant due to concerns of trust and adherence despite similar presentation as a White patient; social history and adherence were the most significant factors contributing to not allocating heart transplant.⁷² Bias against minoritized groups can disadvantage them during the allocation of life-saving HF therapies. During public health emergencies when healthcare professionals have heightened stress and less time to process, this is the perfect setting for biased care to occur since there is reliance on automatic or habitual decision-making.⁷³ Minoritized racial and ethnic groups may be at higher risk of receiving biased care. This may explain worse delivery of GDMT for minoritized racial and ethnic patients with acute myocardial infarction during the COVID-19 pandemic compared to White patients ⁷⁴ as summarized in Figure 1 .

Figure 1.

The interplay between COVID-19 infection and heart failure. Biologic risk factors (such as diabetes, obesity, coronary disease, tobacco use, etc.) combined with socioeconomic risk factors (such as inequalities in access to healthcare, education, wealth, high resource neighborhoods, etc.) increase risk of heart failure and COVID-19 infection. The rapid development of vaccines, therapies and rapid diagnostic kits for COVID-19 as well as ongoing clinical trials have led to the resolution of the pandemic. A similar scenario has been seen in heart failure, where the use of guideline directed medical therapy, implantable defibrillators, cardiac resynchronization therapy, left ventricular assist devices and cardiac transplantation have led to improvement in the mortality of this condition. However, unequitable delivery of treatment and care contribute to racial and ethnic disparities. Community based participatory research and implementation science focused on strategies that address overlapping barriers may improve outcomes for both heart failure and COVID-19.

Additional studies are needed to test strategies to correct major etiologies of inequitable HF care delivery such as clinical inertia, social determinants of health (e.g., underinsurance), bias, and structural racism. This will lead to better delivery of HF care and better preparedness during future public health emergencies.

Steps To Address Barriers

Clinical inertia may be addressed through systematic changes in the care delivery process.

Recently, data from the Safety, tolerability, and efficacy of up-titration of guideline-directed medical therapies for acute HF (STRONG-HF) trial was published. ⁷⁵This study revealed that early and frequent outpatient visits for patients presenting with acute HF increased likelihood of prescribing goal doses of HF GDMT compared to usual care and resulted in lower risk of combined death or future HF hospitalization. Although minoritized racial and ethnic groups were not well represented in this study, findings can still be extrapolated. In addition, standardized reminders for up titrating HF GDMT in the electronic medical record may help with clinical inertia as was observed in several single center studies.^{76 , 77}

Uninsurance and SDOH remain major barriers to appropriate HF care. Approaches to address these issues may warrant identifying community and institutional resources to allocate to patients when needed. ⁷⁸At times technology such as telemedicine may be helpful to improve access to care, but investments aimed at narrowing the “digital divide” are needed.⁷⁹ Overall, healthcare systems must consider moving towards routine assessment of SDOH followed by management of SDOH. It has long been recognized that addressing SDOH are vital for improving health care disparities. ^80-82This line of research has been underfunded. ^83,84Additional support of studies that engage community based participatory research and implementation science may finally lead to equity.

Bias and structural racism are principal drivers of health care disparities. ⁸⁵Therefore to achieve equity, concerted efforts are needed that cohere around eliminating structural racism from all facets of society. The agency for change is at the individual, corporate, community, healthcare systems, state and national levels. Initiatives that actively promote diversity, equity, and inclusion (DEI) are an important tenet toward this end (e.g. healthcare work force diversification, DEI in clinical trials etc.).⁸⁶ Many strategies are structural (neighborhood and housing conditions for all people) or policy frameworks (e.g. enacting of universal healthcare access), but some can be individual. Evidence-based bias reduction training have helped enhance diverse hiring and selection of trainees as well as contribute to more equitable culture.^{87 , 88} These same training courses may translate to better prescribing and allocation of therapies to minoritized racial and ethnic groups. In addition, a diverse and inclusive workforce may help reduce cardiovascular access disparities for patients with HF. For example, studies have reported that Black patients consistently experienced poorer communication quality, information-giving, patient participation, and participatory decision-making than White patients in studies examining concordance of physician-patient interactions.⁸⁹

Conclusions

The COVID-19 pandemic highlighted existing inequities in HF care among minoritized racial and ethnic groups. Minoritized racial and ethnic groups had disproportionately worse cardiovascular outcomes during the pandemic including higher rates of death. The pandemic demonstrated the urgency to address clinical inertia, SDOH, bias, and structural racism. Equity in HF care may be achieved using strategies that bring about standardization of optimal HF treatment, creatively address SDOH using community and institutional resources, and support systematic and individual changes to address structural racism and bias. Therefore, it is paramount to support research focused on strategies to correct disparities such as community based participatory research and implementation science.

Clinics Care Points

Uncited reference

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