Inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the United Kingdom

Widening gap in life expectancy between patients with heart failure living in most and least deprived areas: a longitudinal cohort study

BACKGROUND

Socioeconomic deprivation is associated with adverse clinical outcomes in patients with heart failure (HF). However, in the context of improved medical and device therapy for HF, it is unknown whether the influence of socioeconomic deprivation on HF outcomes is changing over time, especially in relation to evolving life expectancy patterns in the general population. Therefore, we aimed to describe temporal trends in the association of socioeconomic deprivation with loss of actuarially predicted life expectancy amongst ambulatory patients with HF.

METHODS

Between 2006 and 2014, 1802 patients (73.2% male, mean age 69.6 years) with HF and left ventricular ejection fraction ≤ 45% were consecutively recruited across four hospitals in the United Kingdom (UK). Patients were stratified into socioeconomic deprivation tertiles defined by the UK Index of Multiple Deprivation (IMD) score with IMD tertile 1 denoting the least deprived and IMD tertile 3 the most deprived. The primary outcome was all-cause mortality, and relative survival predictions-in relation to age- and sex-matched background mortality rates-were calculated using UK National Life Tables. Relative survival was illustrated in terms of excess mortality risk and years of life expectancy lost. Recruitment period was split into 3-year intervals (2006-2008, 2009-2011 and 2012-2014).

RESULTS

During a median follow-up of 5.0 years, 1302 participants (72.3%) died. Unadjusted mortality rate was highest in tertile 2. However, adjusted to the age-sex matched UK population, a stepwise increase in excess mortality risk was observed across tertiles, with tertile 1 experiencing an excess mortality risk of 11.1% (95% CI: 6.1-16.1%) and tertile 3 24.2% (95% CI: 19.4-28.0%). This corresponded to a loss of life expectancy of 1.76 years (95% CI: 1.50-2.03) for tertile 1 and 2.30 years (95% CI: 2.03-2.57) for tertile 3 over a 10-year period. We observed disparity in actuarial survival between tertiles over time, with participants in tertile 1 losing less life expectancy at 10 years compared to those in tertiles 2 and 3. However this was only statistically significant for those recruited between 2012 and 2014 (p < 0.05).

CONCLUSIONS

The impact of socioeconomic deprivation on HF outcomes in an unselected diverse UK population appears to have worsened over time.

Assessing ethnicity as a factor in myocardial infarction emergency response and recovery: a study from the Negev Desert

BACKGROUND

We compared short- and long-term management and outcomes between Bedouin Arabs and Jewish patients in the Negev region (Israel) to assess disparities in myocardial infarction care and subsequent impacts on patient health.

METHODS

A retrospective cohort study was conducted at Soroka University Medical Center, Israel, spanning from 2016 to 2022. It included all cases of ST elevation myocardial infarction (STEMI) requiring urgent catheterisation. Data were extracted on demographics, comorbidities and key time metrics from symptom onset to intervention. Outcomes included in-hospital mortality, 1-year mortality and 1-year mortality for those who survived and were discharged.

RESULTS

Among the 1530 participants (1092 Jews, 438 Bedouins), no significant differences were found in immediate treatment metrics. However, multivariable logistic regression revealed a difference in a long-term outcome; Bedouins had a higher risk of 1-year mortality (adjusted OR=1.49, 95% CI: 0.99 to 2.22).

CONCLUSIONS

While the initial treatment outcomes for STEMI appear comparable between ethnic groups, ethnic disparities become apparent in long-term health outcomes. Tailored interventions such as improved follow-up systems, community-specific health education and enhanced access to rehabilitation services are essential for ensuring equitable health outcomes for all populations.

Ethnic disparities in STEMI outcomes among older adults: a comparative study of bedouins and jews

BACKGROUND

ST-Elevation Myocardial Infarction (STEMI) is a critical condition, especially in the older population, who are at increased risk due to comorbidities and delayed diagnosis. This study aimed to investigate the impact of ethnicity on the clinical characteristics, treatment timelines, and outcomes of older patients with STEMI in southern Israel, comparing Jewish and Bedouin populations.

METHODS

We conducted a retrospective cohort study at Soroka University Medical Center from 2016 to 2022, including older patients (≥ 65 years) diagnosed with STEMI. Patients were grouped by ethnicity: Jews and Bedouins. Data on demographics, comorbidities, treatment timelines, and clinical outcomes were collected. Statistical analysis included a comparison analysis and a multivariable logistic regression, adjusting for potential confounders.

RESULTS

575 older patients diagnosed with STEMI were included in the study, of them 469 Jews (81.6%) and 106 Bedouins (18.4%). The mean age of the cohort was 74.35 ± 7.33 years, with no significant difference between Jews (74.56 years 7.53) and Bedouins (73.40 ± 5.99 years, p = 0.139). Bedouins had higher rates of diabetes (53.8% vs. 40.7%, p = 0.019) and smoking (40.6% vs. 27.9%, p = 0.015) and were less likely to arrive by ambulance (39.6% vs. 62.5%, p < 0.00). Bedouins also experienced longer median times from pain onset to first medical contact (126.5 min vs. 90.0 min, p = 0.006) and total ischemic time (240.0 min vs. 205.0 min, p = 0.003). Despite these differences, there were no significant differences in in-hospital mortality (13.2% Bedouins vs. 10.9% Jews, p = 0.606), 30-day mortality (14.2% Bedouins vs. 11.5% Jews, p = 0.556), or one-year mortality (21.7% Bedouins vs. 20.9% Jews, p = 0.959). Multivariable analysis confirmed no significant association between ethnicity and mortality outcomes.

CONCLUSIONS

Despite the higher prevalence of comorbidities among Bedouin patients, less likely to arrive by ambulance, and experienced longer delays in receiving care, their mortality outcomes were comparable to Jewish patients. These findings highlight the effectiveness of the acute care system in southern Israel. However, further research is needed to explore potential differences in other outcomes, such as quality of life and functional recovery, to better address healthcare disparities in this population.

Surgical and transcatheter aortic valve interventions for aortic stenosis in England: sociodemographic variations in treatment trends and outcome over 20 years

BACKGROUND

Health inequalities in cardiovascular care have been identified in the UK. The sociodemographic characteristics of patients undergoing intervention for aortic stenosis (AS) in England, and the impact of COVID-19, is unknown.

METHODS

National linked data sets identified all surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) for AS, and post-intervention cardiovascular mortality, between 2000 and 2023.

RESULTS

Of 179 645 procedures, there were 139 990 SAVR (mean age 71±10.8 years, 64% male, 96.0% white) and 39 655 TAVI (mean age 81±7.7 years, 57% male, 95.7% white). Rates of SAVR declined during COVID-19 for all groups, but TAVI rates increased steadily. Women were older; ethnic minority groups and those from most deprived areas were younger, with greater comorbidities. Women and more deprived groups had lower rates of SAVR (age-standardised rates per 100 000 in 2020-2023: 17.07 vs 6.65 for men vs women; 9.82 vs 10.10 for Index of Multiple Deprivation (IMD)-1 vs IMD-5) and TAVI (20.20 vs 9.79 for men vs women; 9.55 vs 13.36 for IMD-1 vs IMD-5). These discrepancies widened over time. Ethnic differences were observed for SAVR, with the lowest rates in black patients. Cardiovascular mortality post-intervention was lower in female patients and with decreasing deprivation, with no ethnicity-based differences.

CONCLUSIONS

There are differences in intervention rates for AS in England, with lower rates in female patients and to a lesser extent, those from the most deprived areas and ethnic minority groups. These variations have widened over time. Post-intervention cardiovascular mortality is lower in women and with decreasing deprivation. Public health measures and research are needed to identify the true prevalence of AS in different populations, and the reasons for potential inequalities.

Trends of acute myocardial infarction-related deaths in US patients from 1999 to 2020

Introduction

The objective of this study was to analyze the temporal trends and demographic/geographical disparities in acute myocardial infarction (AMI)-related mortality among individuals aged 15 and older across the United Sates (US).

Material and methods

We evaluated death records from 1999 to 2020 that were obtained from the CDC WONDER database. Age-adjusted mortality rates (AAMRs) per 100,000 persons and annual percent changes (APC) were computed, with stratification by year, sex, race/ethnicity, and geographic region.

Results

Between 1999 and 2020, 3,016,546 AMI-related deaths were reported in the United States. The overall AAMR was 51.9 per 100,000 (95% CI: 51.8-52.0). Over the course of the study, the crude mortality rate (CMR) increased with age. Males exhibited a consistently higher overall annual AAMR (67.4, 95% CI: 67.3, 67.5) than females (39.5, 95% CI: 39.4, 39.6). In comparison to other races, Black (or African American) people had the highest death rates, with an AAMR of 58.9 (95% CI: 58.7, 59.1). The South region mortality rate (AAMR = 57.7; 95% CI: 57.6, 57.8) was higher than that of the Northeast, Midwest, and West. Specifically, Kentucky had the highest death rate (87.7, 95% CI: 87.0, 88.3), followed by Missouri (80.3, 95% CI: 79.8, 80.8) and Mississippi (85.6, 95% CI: 85.0, 86.6).

Conclusions

During the period from 1999 to 2020, males, Black/African American adults and those living in the South and other nonmetropolitan areas of the country typically had the highest AAMRs.

Actioning atrial fibrillation identified by ambulance services in England: a qualitative exploration

OBJECTIVES

To explore the acceptability and feasibility of detection of atrial fibrillation (AF) by emergency medical services (EMS) and identify potential barriers and facilitators to implementing a formal pathway to facilitate follow-up in primary care, which could reduce the risk of AF-related stroke.

DESIGN

Qualitative study using focus groups and one-to-one interviews guided by a semistructured topic guide.

SETTING

North East England.

PARTICIPANTS

Focus groups with 18 members of the public and one-to-one online interviews with 11 healthcare and service providers (six paramedics and five experts representing cardiology, general practice (GP), public health, research, policy and commissioning).

RESULTS

All participant groups were supportive of a role of EMS in identifying AF as part of routine assessment and formalising the response to AF detection. However, this should not create delays for EMS since rate-controlled AF is non-urgent and alternative community mechanisms exist to manage it. Public participants were concerned about communication of the AF diagnosis and whether this should be 'on scene' or in a subsequent GP appointment. Paramedics reported frequent incidental identification of AF, but it is not always clear 'on scene' that this is a new diagnosis, and there is variation in practice regarding whether (and how) this is communicated to the GP. Paramedics also focused on ensuring the safety of non-conveyed patients and a perceived need for an 'active' reporting process, so that a finding of AF was actioned. Field experts felt that a formal pathway would be useful and favoured a simple intervention without adding to time pressures unnecessarily.

CONCLUSIONS

There is support for the development of a formal pathway to ensure follow-up for people with AF that is incidentally detected by EMS. This has the potential to improve anticoagulation rates and reduce the risk of stroke.

Feasibility study of rehabilitation for cardiac patients aided by an artificial intelligence web-based programme: a randomised controlled trial (RECAP trial)-a study protocol

INTRODUCTION

Cardiac rehabilitation (CR) delivered by rehabilitation specialists in a healthcare setting is effective in improving functional capacity and reducing readmission rates after cardiac surgery. It is also associated with a reduction in cardiac mortality and recurrent myocardial infarction. This trial assesses the feasibility of a home-based CR programme delivered using a mobile application (app).

METHODS

The Rehabilitation through Exercise prescription for Cardiac patients using an Artificial intelligence web-based Programme (RECAP) randomised controlled feasibility trial is a single-centre prospective study, in which patients will be allocated on a 1:1 ratio to a home-based CR programme delivered using a mobile app with accelerometers or standard hospital-based rehabilitation classes. The home-based CR programme will employ artificial intelligence to prescribe exercise goals to the participants on a weekly basis. The trial will recruit 70 patients in total. The primary objectives are to evaluate participant recruitment and dropout rates, assess the feasibility of randomisation, determine acceptability to participants and staff, assess the rates of potential outcome measures and determine hospital resource allocation to inform the design of a larger randomised controlled trial for clinical efficacy and health economic evaluation. Secondary objectives include evaluation of health-related quality of life and 6 minute walk distance.

ETHICS AND DISSEMINATION

RECAP trial received a favourable outcome from the Berkshire research ethics committee in September 2022 (IRAS 315483).Trial results will be made available through publication in peer-reviewed journals and presented at relevant scientific meetings.

TRIAL REGISTRATION NUMBER

ISRCTN97352737.