What February Brings :

February marks many things—the shorter month means fewer call shifts for a weary resident; the truncated month is also one for avoiding planning a favorite rotation in. It is the month to wear red in honor of love or to honor American Heart Month; and it is the month to remind us of the incredible contributions of Black Americans. As I write this blog at the conclusion of 2020, I reflect on one aspect of medical care the pandemic highlighted: the differing vulnerabilities among our patients and racial disparities.

In pediatric cardiovascular medicine, the numbers speak for themselves: Black and Hispanic children admitted with myocarditis or cardiomyopathy are more likely to die in the hospital admission.¹ Furthermore, Black children have higher rates of mortality and rejection in the first 5 years after a heart transplant.² Black children are more likely to die after a complication after congenital heart surgery,³ and a greater proportion of Black children die after congenital heart surgery without receiving extracorporeal membrane oxygenation (ECMO) support.⁴

These data are sobering and, while they are not new, we are recognizing these realities more and more every day. They prompt the harder questions.

Are these children presenting to care later and are hence sicker? Are they less likely to see their primary care provider because their parents cannot afford to miss an afternoon at work, and so they come into our emergency rooms in extremis?⁵ If one out of three Black males is expected to be sentenced to prison, does that statistic affect how we consider the parents’ “social situation” and thus a child’s candidacy for any advanced therapy?⁶ Are difficulties with transportation leading to missed immunosuppression monitoring visits and poor transplant graft health downstream?⁷ And finally, what implicit biases do we hold in the hospital that makes (or breaks) someone’s candidacy for ECMO?

The answer to the last question is most likely to be all of the above, and the solutions likely lie in a multi-pronged approach. Our professional societies, including the American Academy of Pediatrics (AAP), the American Heart Association (AHA), and the Pediatric Heart Transplant Society (PHTS), are supporting studies that make deeper dives into the disparities associated with race and ethnicity, the interwoven socioeconomic context of the same, and how we can make these social assessments of risk more meaningful by using them to mitigate the said risk. Guidelines are more consciously reflective of the socioeconomic ramifications as well as the individual risks of each family based on their race and are allowing more room for shared decision making.

By the time you are reading this, the pandemic may be easing up and not at the forefront of issues in your local area. Even so, it is important to not lose sight of the important red flag issues it brought to light. None of these are new, but the delay in action has already cost us much in terms of morbidity and mortality. We remain hopeful that the new year will also bring new data and strategies on how we can improve on these racial disparities in care.

As Dr. Zenel alluded to in his blog last month, 2020 taught us many lessons and in doing so uncovered new issues that we cannot ignore. Racial disparities in cardiovascular health outcomes is a prime one, and an acceleration in engagement and action is a requirement.

References:

1. Olsen J, Tjoeng YL, Friedland-Little J, Chan T. Racial disparities in hospital mortality among pediatric cardiomyopathy and myocarditis patients. Pediatr Cardiol. 2020 Oct 6. doi: 10.1007/s00246-020-02454-4. Epub ahead of print. PMID: 33025028.
2. Green DJ, Brooks MM, Burckart GJ, Chinnock RE, Canter C, Addonizio LJ, Bernstein D, Kirklin JK, Naftel DC, Girnita DM, Zeevi A, Webber SA. The influence of race and common genetic variations on outcomes after pediatric heart transplantation. Am J Transplant. 2017 Jun;17(6):1525–1539. doi: 10.1111/ajt.14153. Epub 2017 Jan 23. PMID: 27931092.
3. Chan T, Lion KC, Mangione-Smith R. Racial disparities in failure-to-rescue among children undergoing congenital heart surgery. J Pediatr. 2015 Apr;166(4):812-8.e1–4. doi: 10.1016/j.jpeds.2014.11.020. Epub 2014 Dec 30. PMID: 25556012.
4. Chan T, Barrett CS, Tjoeng YL, Wilkes J, Bratton SL, Thiagarajan RR. Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery. J Thorac Cardiovasc Surg. 2018 Jul;156(1):306–315. doi: 10.1016/j.jtcvs.2018.02.103. Epub 2018 Apr 6. PMID: 29681396.
5. Tillman AR, Colborn KL, Scott KA, Davidson AJ, Khanna A, Kao D, McKenzie L, Ong T, Rausch CM, Duca LM, Daley MF, Coleman S, Costa E 3rd, Fernie E, Crume TL. Associations between socioeconomic context and congenital heart disease related outcomes in adolescents and adults. Am J Cardiol. 2020 Oct 24:S0002–9149(20)31146-2. doi: 10.1016/j.amjcard.2020.10.040. Epub ahead of print. PMID: 33203514.
6. https://www.naacp.org/criminal-justice-fact-sheet/
7. D'Agostino EM, Patel HH, Hansen E, Mathew MS, Nardi MI, Messiah SE. Does transportation vulnerability explain the relationship between changes in exposure to segregation and youth cardiovascular health? Health Place. 2019 May;57:265–276. doi: 10.1016/j.healthplace.2019.04.002. Epub 2019 May 24. PMID: 31132717.
8. Lopez KN, Morris SA, Sexson Tejtel SK, Espaillat A, Salemi JL. US mortality attributable to congenital heart disease across the lifespan from 1999 through 2017 exposes persistent racial/ethnic disparities. Circulation. 2020 Sep 22;142(12):1132-1147. doi: 10.1161/CIRCULATIONAHA.120.046822. Epub 2020 Aug 3. PMID: 32795094; PMCID: PMC7508797.