Raising awareness, improving access key to reducing heart valve disease disparities
Today is Heart Valve Disease Awareness Day, which serves as a reminder that while many advancements have been made in the treatment of heart valve disease, not all patients have been able to take advantage of them.
One doctor who has made great efforts to promote awareness of aortic stenosis and other chronic and structural heart diseases is V. Antoine Keller, MD, FACC, FACS, a CV, endovascular and thoracic surgeon at Ochsner Lafayette General Hospital in Louisiana and the co-founder of HeartSense, an organization aiming to reduce heart health disparities by providing access to heart health screening and education in disadvantaged communities.
Through its Healthcare Disparities Screening Project, the organization hosts screening events in which community members are provided information about and, using a system combining an ECG and a digital stethoscope (Eko DUO, Eko), screened for aortic stenosis, atrial fibrillation, mitral regurgitation and congestive HF.
Healio spoke to Keller about disparities in the diagnosis and treatment of aortic stenosis and other heart diseases, the issues related to disparities in access to care and programs that could help reduce disparities by raising awareness about chronic and structural heart diseases.
Healio: What are the most prominent signs and symptoms of aortic stenosis? Do these vary by population?
Keller: It is important for people to understand that the signs of aortic stenosis are very common to a lot of conditions. If you have any of these signs or symptoms, you should be examined by a health care professional to determine whether it is something you need to worry about.
The most common signs and symptoms of aortic stenosis are typically shortness of breath and decreased exercise tolerance, but chest pain and symptoms typical of a MI can also be present. A lot of people feel like they are just getting older and slowing down, because these are symptoms common to getting older, but often it can be something more serious like valvular heart disease. Almost always, there is a heart murmur which could alert the primary care doctor to refer the patient to someone who specializes in CV medicine.
One patient I had was recovering from knee surgery. Her orthopedist did not feel she was making a good enough recovery, so he sent her to me. I started asking her questions about her lifestyle. She said she walked every day. In southern Louisiana, women are commonly found mowing their lawns, so I asked her if she mowed her lawn every week, and she said yes. I asked her if she had chest pain or shortness of breath after she mowed her lawn. She said, “Oh no, ever since I bought that riding mower, I don’t have chest pain or shortness of breath anymore.” But when she was pushing her mower, she had shortness of breath, and she modified her lifestyle to accommodate those symptoms. When her doctor asked her if she had shortness of breath when she mowed her lawn, she said no. But he did not ask her if she was riding or pushing. Understanding the nuances of valvular heart disease is very important, especially when you are taking a history from an older person. If you have these symptoms when you are exercising, it is as important as when you have them at rest.
Healio: To what extent are there disparities in the diagnosis and treatment of heart valve disease?
Keller: One of the things we have learned with the advent of transcatheter aortic valve replacement is that aortic stenosis is undertreated across the board in all populations. The interesting thing about TAVR is that Black and white patients have the same expectation of a favorable outcome if they have TAVR; there is no disparity. Yet, Black patients receive TAVR at much lower rates than white patients do. Indeed, Black patients are more likely to get surgical therapy than white patients are, which is attended by a greater risk for mortality just from having the surgery. Not only are Black patients not having as much exposure to new technology and techniques, but they also often present later in the disease process for diagnosis and consequently have a higher mortality risk just from having a diagnosis of late-stage aortic stenosis.
Poverty also has a significant impact on whether someone has access to new technology for treatment of aortic stenosis. As patients’ household income increases, they have a better chance of having TAVR as opposed to conventional open heart surgery. This impacts rural communities, especially those not in proximity to TAVR centers. The disparities not only impact racial and ethnic minorities, but also socioeconomic minorities and people from disadvantaged communities.
Healio: There has been a lot of research released recently about how TAVR centers are more likely to be concentrated in major metropolitan areas and wealthier areas. To what extent is that contributing to these disparities?
Keller: It makes a big difference. Cultural determinants play a big part in whether someone is diagnosed with aortic stenosis and treated for it. These factors include transportation issues, child care issues and not wanting to be alone in a hospital that is far away from home. Some people do not live in a place where there is somewhere close to them where they can get a diagnosis rendered by an echocardiogram or by a CV professional with specialized expertise, because it takes all day to get somewhere on a bus or they cannot find someone to care for their kids while they go to the doctor for the day or they don’t feel like they can trust the medical establishment because of past incidents like the Tuskegee experiment.
All of these cultural determinants of care can have a significant impact on whether someone receives a diagnosis of aortic stenosis and subsequently gets treatment. And so, while someone in a disadvantaged community who gets TAVR has the same expectation of a favorable outcome as someone who comes from a majority community, it really is a question of access. The COVID-19 pandemic brought sharp relief onto the situation of access to care; many more vaccinations and tests have been conducted in wealthier communities and far fewer in less advantaged communities. This is true for access to physicians treating all kinds of CVD as well. People that are disadvantaged don’t necessarily have access to physicians with specialized expertise.
Healio: What can be done to address these disparities?
Keller: Raising awareness is one of the most important things, because in communities in which there are fewer health care practitioners that have the specialized expertise and training, there are fewer people who are bringing to top of mind these issues related to CVD, which kills more people in the U.S. than all types of cancer combined. People are more likely to say they would rather have heart disease than cancer, and only when they are educated about the importance of heart disease in their daily lives will they acquiesce and say they don’t want heart disease and need to learn more about CV wellness.
One of the initiatives that we have put forth in the community is the HeartSense Healthcare Disparities Screening Project. We try to educate people in disadvantaged communities about CVD. We want to make evaluation for structural heart disease a wellness issue, much like hypertension, dyslipidemia and smoking. The population is getting older, and more people are going to be at risk for developing aortic stenosis and other forms of structural heart disease.
Of note, Black and Hispanic populations are growing at much faster rates than other populations, and it is expected by 2050 that one of five African American and Hispanic people will be older than 60 years. It is going to be a significant public health problem for us and it’s important for us to get ahead of it. The best way to get ahead of it is education.
Healio: What other resources might be available?
Keller: There are a number of other initiatives that have been trying to get Americans to pay attention to their numbers. The American Heart Association has a fantastic resource for understanding where you are and where your risk lies.
Our HeartSense initiative is one place where you can go online and find out information about CVD that could potentially help you live a healthier life. It has information on aortic stenosis and other kinds of chronic heart disease.
There are other initiatives such as My AS Journey that can help people come to grips with the fact that CV wellness is important, to guide them on their journey from a diagnosis of aortic stenosis to treatment in their convalescence and to help them find information that is up to date.
Healio: Is there anything else you’d like to mention?
Keller: It’s important for people to know that disparities in structural heart disease are largely related to access to care. Outcomes are similar in all different populations if access is equal. We have to reduce barriers to access. The best way for us to do that is to educate primary care doctors and patients about structural heart disease, and chronic heart disease in general. That means going into the community to visit with people and to attempt to count people who have been uncounted for a long time, who live in places where the treatment rates for aortic stenosis are very low compared to other disease processes. A lot of this has to do with lack of education. For example, people need to understand that you can develop a heart murmur as you age; it doesn’t necessarily have to be there from the time you were born. As people get older, they need to understand that they should have regular checkups with their physician, and surveillance if they happen to have some sort of valvular heart disease.
- American Heart Association. www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valve-problems-and-causes/problem-aortic-valve-stenosis. Accessed Feb. 16, 2022.
- HeartSense Healthcare Disparities Screening Project. https://heart-sense.org/screening-impact. Accessed Feb. 16, 2022.
- My AS Journey. myinteractiveasjourney.com. Published Feb. 22, 2022. Accessed Feb. 22, 2022.
For morew information:
V. Antoine Keller, MD, FACC, FACS, can be reached at firstname.lastname@example.org.