Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review.

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Assessing and Addressing Social Determinants of Cardiovascular Health: JACC State-of-the-Art Review.

Social determinants of health (SDOH) are the social conditions in which people are born, live, and work. SDOH offers a more inclusive view of how environment, geographic location, neighborhoods, access to health care, nutrition, socioeconomics, and so on are critical in cardiovascular morbidity and mortality. SDOH will continue to increase in relevance and integration of patient management, thus, applying the information herein to clinical and health systems will become increasingly commonplace. This state-of-the-art review covers the 5 domains of SDOH, including economic stability, education, health care access and quality, social and community context, and neighborhood and built environment. Recognizing and addressing SDOH is an important step toward achieving equity in cardiovascular care. We discuss each SDOH within the context of cardiovascular disease, how they can be assessed by clinicians and within health care systems, and key strategies for clinicians and health care systems to address these SDOH. Summaries of these tools and key strategies are provided.

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease.

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss.

The loss of 50% blood volume is one accepted definition of massive haemorrhage, which ordinarily would trigger the massive transfusion protocol, involving the administration of high ratios of fresh frozen plasma and platelets to allogeneic red cells. We investigated 53 patients who experienced >50% blood loss during open elective abdominal aortic aneurysm surgery to assess allogeneic blood component usage and coagulopathy. Specialist patient blood management practitioners used a tailored cell salvage technique including swab wash to maximise blood return. We assessed the proportion of patients who did not require allogeneic blood components and develop evidence of coagulopathy by thromboelastography (TEG) parameters. Blood loss was 50%-174% (mean [SD] 68% [27%]) of blood volume. The mean (SD) intraoperative decrease in haemoglobin concentration, assessed by arterial blood gas analysis, was 5 (13) g/l. No patient received allogeneic red cells intraoperatively. Four of the 53 (8%) patients received blood components in the first 24 h postoperatively at the anaesthetists' discretion. No patient had intraoperative TEG changes indicative of fibrinolysis or coagulopathy. The 30-day mortality was 2% (one of 53). Reduction of allogeneic transfusion is one aim of patient blood management techniques. We have demonstrated virtual avoidance of allogeneic blood product transfusion despite massive blood loss. These data show possible alternatives to the current massive transfusion protocols to the management of elective vascular surgical patients.

Eliminating Disparities in Cardiovascular Disease for Black Women: JACC Review Topic of the Week.

Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women.

Late Complication of Quadricuspid Aortic Valve: Early Moderate to Severe Aortic Regurgitation.

Quadricuspid aortic valve (QAV) is a rare congenital cardiac anomaly. A normal aortic valve has three cusps, but cases of unicuspid, bicuspid, and quadricuspid aortic valves have been reported. Although QAV usually appears as an isolated congenital anomaly, it may also be associated with other heart conditions. In comparison to the bicuspid aortic valve (BAV) that results in aortic stenosis by the early 50s due to age-related early calcification, this case series suggests that patients with QAV are likely to develop moderate to severe aortic regurgitation in their late 40s or early 50s. Most patients with QAV require tricuspidalization, which is the preferred method for QAV surgical repair, especially in patients with associated aortic regurgitation. The condition was previously diagnosed intraoperatively or postpartum. Today, with imaging modalities like transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and cardiac magnetic resonance imaging, more cases of QAV have been diagnosed in asymptomatic individuals. We present a case series of a previously healthy 49-year-old male and a 47-year-old female who had similar presentations of acute congestive heart failure (CHF). An echocardiogram confirmed that both patients had heart failure with reduced ejection fraction, dilated cardiomyopathy, QAV, and moderate to severe aortic valve regurgitation on echocardiogram. The male patient had an ejection fraction (EF) of 30-35% and a QAV with partial fusion of the leaflets, resulting in a functionally bicuspid aortic valve, while the female patient had an EF of 25-30% with what appears to be a type III QAV according to Nakamura et al. classification. The purpose of this case series is to highlight another potential late complication of congenital QAV.

One lung ventilation.

Anaesthetists might prefer two lungs for ventilation, but this is not always possible. One lung ventilation requires a good knowledge of physiology, anatomy and equipment. This article gives an overview of the basics.

Socioeconomic Determinants of Health and Cardiovascular Outcomes in Women: JACC Review Topic of the Week.

Socioeconomic disparities in cardiovascular risk factors and outcomes exist among women, particularly those of minority racial or ethnic backgrounds. Barriers to optimal cardiovascular health begin early in life-with inadequate access to effective contraception, postpartum follow-up, and maternity leave-and result in excess rates of myocardial infarction, stroke, and cardiovascular death in at-risk populations. Contributing factors include reduced access to care, low levels of income and social support, and lack of diversity among cardiology clinicians and within clinical trials. These barriers can be mitigated by optimizing care access via policy change and improving physical access to care in women with geographic or transportation limitations. Addressing structural racism through policy change and bolstering structured community support systems will be key to reducing adverse cardiovascular outcomes among women of racial and ethnic minorities. Diversification of the cardiology workforce to more closely represent the patients we serve will be beneficial to all women.

Barriers, Opportunities, and Challenges in Addressing Disparities in Diet-Related Cardiovascular Disease in the United States.

In the United States, cardiovascular disease (CVD) is the leading cause of death and disability. Suboptimal diet quality is responsible for a greater percentage of CVD-related morbidity and mortality than any other modifiable risk factor. Further troubling are the stark racial/ethnic and socioeconomic disparities in diet quality. This represents a major public health concern that urgently requires a coordinated effort to better characterize the barriers to healthy dietary practices in population groups disproportionally affected by CVD and poor diet quality to inform multifaceted approaches at the government (policy), community environment, sociocultural, and individual levels. This paper reviews the barriers, opportunities, and challenges involved in shifting population behaviors, especially in underserved populations, toward healthy dietary practices. It is imperative that public health policies address the social determinants of nutrition more intensively than previously in order to significantly decrease CVD on a population-wide basis.

Peripartum cardiomyopathy and HELLP syndrome in a previously healthy multiparous woman: A case report.

Peripartum cardiomyopathy is a type of dilated cardiomyopathy in which the exact etiology is uncertain. HELLP syndrome is characterized by a constellation of different clinical and laboratory findings, including hemolysis, elevated liver enzymes, and low platelets. Few case reports exist detailing successful diagnosis and management of postpartum HELLP syndrome, peripartum cardiomyopathy, and multisystem organ failure in a previously healthy woman. We herein report the case of a 39-year-old multiparous female with mild gestational hypertension, who presented in the third trimester with vaginal bleeding and was subsequently suspected to have intrapartum placental abruption leading to immediate Cesarean section, complicated by massive postpartum hemorrhage, necessitating care in the intensive care unit. HELLP syndrome, disseminated intravascular coagulation, and acute kidney injury requiring hemodialysis subsequently developed along with respiratory failure and peripartum cardiomyopathy. After diagnosis and proper management, the patient made a full recovery. Peripartum cardiomyopathy should remain on the differential for women with heart failure symptoms.

Idiopathic dilated cardiomyopathy: a common but mystifying cause of heart failure.

While researchers try to elucidate the origins of idiopathic dilated cardiomyopathy, clinicians continue to face the challenges of identifying and treating the causes of this condition to improve symptoms and survival. We review classification schemes for dilated cardiomyopathy and the current range of diagnostic and therapeutic options and treatment goals.