Aubrey J. Grant, MD – The Early Career Voice

Bias

April 12, 2021April 9, 2021 Aubrey J. Grant, MD

A middle-aged black woman presents to her local emergency department via emergency medical services (EMS) with chest and back pains, nausea, and vomiting. She has a history of IV drug abuse and is disheveled in appearance. Prior to her arrival, EMS notes that her chest pain appears non-cardiac and provides supportive care while en route to the hospital. She is triaged to the appropriate care and an emergency provider assesses the patient.

The patient continues to have chest discomfort and nausea. The emergency team agrees with the EMS assessment and deems her symptoms as atypical for a cardiac etiology. An EKG is performed which demonstrates subtle ST-segment elevations in her inferior leads as well as faint reciprocal changes. However, the catheterization lab was not activated at this point.

High sensitivity troponin ultimately revealed a modest enzyme leak and the cardiology team was consulted. The patient was urgently taken to the cath lab to reveal an acute lesion of her proximal right coronary artery. There were no complications during the procedure and she ultimately had an uneventful hospital course.

Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. These biases are activated involuntarily, without an individual’s awareness or intentional control. Unfortunately, we are all susceptible to bias and there is extensive evidence showing how bias can lead to differential treatment of patients by race, gender, age, weight, language, socioeconomic status, and insurance status. As such, it begs the question, if our patient had no history of drug abuse or was white, would their acute myocardial infarction been treated faster?

A seminal 2007 study of internal medicine and emergency medicine residents found that, while the participants reported no explicit racial bias, Implicit Association Tests (IATs) indicated an implicit preference towards White Americans. Further, the higher the preference, the more likely that physician was to treat Whites and not treat Blacks with early thrombolysis in the setting of acute myocardial infarction.

While it is clear the effects of implicit bias in medicine, it is also clear that implicit bias is malleable. There are a number of leading strategies for combating implicit bias including stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for contact with individuals from different groups. Further, new research must be conducted to find more innovative techniques for managing implicit bias. As clinicians, it is our responsibility to be constantly aware of our bias and to actively work to address that bias in every patient encounter.

References

Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238. doi:10.1007/s11606-007-0258-5

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

Entresto Use in Heart Failure w Preserved Function

March 11, 2021March 12, 2021 Aubrey J. Grant, MD

Heart failure is a pervasive diagnosis and unfortunately about 6.2 million adults in the United States suffer from this disease.¹ Furthermore, heart failure represents a significant proportion of total healthcare expenditures including the cost of healthcare services, medicines to treat heart failure, and missed days of work. While we often focus on the management of heart failure with reduced ejection fraction, epidemiological studies report about 50% of all heart failure patients have preserved function.² Heart failure patients with preserved function have similar rates of hospitalization and death when compared to heart failure patients with reduced function.²

While there are several treatment options that have proven mortality benefit in chronic heart failure patients with reduced function, the treatment options for patients with preserved function are limited.

Following the results of the PARADIGM-HF trial, PARAGON-HF was an industry funded, multi-national, double blinded trial that attempted to determine whether entresto was more effective than valsartan at lowering the rate of total hospitalizations for heart failure and death from cardiovascular causes. The investigators of this trial randomly assigned 4822 patients with symptomatic heart failure with preserved function (left ventricular ejection fraction [LVEF] ≥ 45%) to entresto or valsartan alone. The primary endpoint was total hospitalizations for heart failure and death due to cardiovascular causes.

Regarding the patient group studied; the mean age of the patients was 73 years, 52% were female, only 2% were black, and the average ejection fraction was approximately 57%. The investigators found that entresto did reduce the rate of the primary endpoint by 13% (rate ratio, 0.87; P = .06). The data shows that the lower event rate was mostly driven by fewer hospitalizations for heart failure. Notably, death due to cardiovascular causes was essentially the same with 204 deaths in the Entresto group and 212 deaths in the valsartan group.³

Following the PARAGON-HF trial, the FDA has now granted an expanded indication to Entresto that would allow for use of the therapy in at least some patients with heart failure and preserved ejection fraction (HFpEF). The manufacturer Novartis touts that this is the first time that there is a heart failure treatment with an indication that includes patients with preserved function. While it is truly an amazing feat to now have an FDA indicated drug for this patient population, the effect on hard cardiovascular outcomes as suggested by PARAGON-HF are marginal. Further studies should be conducted to determine whether the drug is more effective in certain patient populations in order to truly understand the potential benefits of entresto in heart failure with preserved function.

Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association external icon Circulation. 2020;141(9):e139-596.
1.Gladden JD, Linke WA, Redfield MM. Heart failure with preserved ejection fraction. Pflugers Arch 2014;466:1037-1053
Solomon SD, McMurray JJV, Anand IS, Ge J, Lam CSP, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, van Veldhuisen DJ, Zannad F, Zile MR, Desai AS, Claggett B, Jhund PS, Boytsov SA, Comin-Colet J, Cleland J, Düngen HD, Goncalvesova E, Katova T, Kerr Saraiva JF, Lelonek M, Merkely B, Senni M, Shah SJ, Zhou J, Rizkala AR, Gong J, Shi VC, Lefkowitz MP; PARAGON-HF Investigators and Committees. Angiotensin-Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction. N Engl J Med. 2019 Oct 24;381(17):1609-1620. doi: 10.1056/NEJMoa1908655. Epub 2019 Sep 1. PMID: 31475794.

Legacy

February 11, 2021February 11, 2021 Aubrey J. Grant, MD

Dr. Elijah Saunders was born in Baltimore City in 1934. As a young student he received a BS degree from Morgan State College in 1956 and he received his MD degree from the University of Maryland School of Medicine in 1960. During his medical studies, he was one of only four African-Americans in his class of 140 students and was instrumental in helping to desegregate the medical wards. He then went on to become the first African-American resident in internal medicine at the University of Maryland School of medicine and the first African-American cardiologist in the state of Maryland in 1965.

Following fellowship, Dr. Saunders led a successful private practice for the first 20 years of his career before he returned to the University of Maryland as a professor in Cardiology, where he pursued research on hypertension among African Americans. For many years, he led the Hypertension Division in the Department of Medicine. His critical research illuminated that ethnicity may influence the response to certain types of antihypertensive medications. As a result of his research and lobbying, it is now standard for trials to require African Americans to be included in research. Over his career, he published more than 50 peer-reviewed articles and eight books.

Beyond his many achievements, including increasing African American representation in cardiovascular drug trials, being a founding member of the Association of Black Cardiologists, and co-founder of Heart House of the American College of Cardiology; Dr. Saunders was known for his positive demeanor, caring disposition, and gentle spirit. As a young black man growing up in Maryland with an interest in cardiology, Dr. Saunders was someone who I always admired. During my fourth year of medical school I spent an away rotation at the University of Maryland in hopes of training under Dr. Saunders, but was saddened to hear of his untimely passing prior to my arrival. However, I eagerly listened to his patient’s detailed stories regarding his intellect, compassion, dedication to health equity, and desire to bring healthcare to non-traditional spaces to reach the most at-risk populations. This experience quickly reaffirmed that Dr. Saunders was the type of cardiologist I hoped to emulate: clinically skilled, empathetic, and a leader in healthcare innovation.

Despite improvements in health distribution inequalities, African-American communities are continuously plagued with cardiovascular disease at an alarming rate. Some of the main contributors to the high burden of disease are the persistent and increasing degrees of limited access to healthy food, low socioeconomic status, and poor nutritional awareness. To address this, Dr. Saunders advocated for community screening and outreach in barbershops and churches in order to engage the black community in non-traditional spaces. In 2006, he developed the Hair, Heart and Health program, an innovative program that trained barbers and hairstylists to pre-screen customers for hypertension and then make referrals for medical care.

I believe as medical professionals we have two profound responsibilities. The first is to be an effective clinician. It is our obligation to treat and heal patients to the best of our abilities, while cultivating and promoting prevention. The second, and perhaps more important, is to go beyond the hospital walls and become an innovator in healthcare. We must identify roadblocks that may impede healthy practices, and provide sustainable solutions for these challenges. I hope that we can all mimic Dr. Saunders’s spirit for innovation and love of patient care.

COVID Fatigue

January 14, 2021January 14, 2021 Aubrey J. Grant, MD

Anesthesia alert! This overhead call alerting pending intubation can be heard bellowing throughout the hallways of my medical center several times throughout the day and is seemingly the soundtrack of COVID-19. My typical routine is to pause, make sure it’s not sounding the alarm to my patient’s room, and then continue with my workday.

It has been 304 days since the WHO has declared COVID-19 a pandemic. COVID numbers at my medical center continue to rise, and although the vaccine is widely available to hospital staff, we are continuing to see some of our highest numbers since the beginning of the pandemic.

As a general cardiology fellow on the advanced heart failure service at a high volume mechanical circulatory support and transplant center, we really get to know our patients while taking care of them during their index hospitalizations. For the past two weeks, I’ve gotten to know one patient in particular. She presented in cardiogenic shock, was stabilized on inotropes and a balloon pump, with plans for upcoming destination therapy LVAD implantation.

Every day when we come to her bedside, she is on FaceTime with her partner. Today, the day before her LVAD implantation, we walked to her bedside, and once again she was on FaceTime with her devoted partner. She is obviously loved. Considering that she was going for LVAD the following day, we spent a bit more time explaining the procedure in-depth to the patient and her partner. After discussing all of the technical details, she timidly asked “Do you think my partner could come to spend the night with me tonight? I just need to see my love and it’s been so long.” You could see the tears begin to drop from her face and her partners.

Donning and doffing, wearing the N95, not knowing what anyone looks like without their mask; things have become routine. Health-care workers have adapted so well to the ever-demanding challenges of practicing medicine in the era of COVID-19. We’ve made guidelines, adjusted our practice, established routines, and found ways to provide quality medical care in the darkest of times. We’ve become oddly accustomed to these necessary rituals in order to protect ourselves, our loved ones, and the patients that we care for.

But none of this is normal.

At that moment, when we told our patient that the person who loved her the most in this world could not sit with her the night before a life-altering surgery, it became dramatically apparent to me that all of this is abnormal. The weight of 304 days of pandemic sat heavy in my heart and the sounds of endless anesthesia alerts echoed in my head.

Depression and burnout were prevalent in the healthcare field even before the pandemic. COVID-19 has undoubtedly placed an added burden on all healthcare providers. I implore people to take time off if you can, spend time with family if able, and be thoughtful of your mental well being because this past year has been anything but normal.

COVID-19 and Historical Distrust

December 18, 2020December 16, 2020 Aubrey J. Grant, MD

As a member of the AHA FIT programming subcommittee, I could not have been more excited about the upcoming scientific sessions meeting. The planning for this meeting began many months in advance with lots of zoom sessions, emails, and organizing to help lay the groundwork for a successful event. As a new member of the committee, I was excited to facilitate the preventative cardiology fireside chat and the racism in medicine discussion.

However, two days prior to the session, I woke up with a terrible headache and I generally felt unwell. Considering the ongoing pandemic, I was concerned that I may be infected with COVID-19. Over the next twenty-four hours, my symptoms worsened and the following morning I tested positive for the virus.

As my illness progressed, I experienced all of the common reported symptoms: myalgias, headaches, cough, shortness of breath, and fevers. The fatigue persisted despite adequate rest. The barking cough was painful, and the constant fevers were so agonizing. The onslaught of symptoms persisted throughout my time in quarantine, and the experience was extremely debilitating. Moreover, Instead of conversing with amazing and thoughtful leaders in the field of cardiology as previously planned, the virus forced me to focus on my own physical well-being.

One of the more insidious, yet profound effects, of the COVID-19 infection, is the effect it has on your mental wellbeing. As a physician who manages COVID patients, I am uniquely sensitive to the dramatic and acute trajectory the disease may take. Being isolated in quarantine for 10-14 days, while intimately perceiving every symptom in fear, was a distinctly stressful symptom of COVID that I could have never predicted. I was confronted with my most crippling fear of progressing to critical condition and needing to be hospitalized. Regardless of the fact that I am a physician, I stared in the face of the reality that as a black man, I have a greater chance of worse outcomes.

The pandemic has further highlighted the disparity in care that exists in this country among different racial and ethnic groups. A recent publication reviewed the American Heart Association (AHA) COVID-19 registry of race and ethnicity data, which included 7,868 hospitalized patients across 88 registry sites from Jan 1 to July 22, 2020, revealed an over-representation of Non-Hispanic Black and Hispanic patients, which accounted for >50% of hospitalizations [1]. Further, these minority patients were significantly younger than patients of other ethnicities at the time of hospitalization [1]. The disproportionate rates of COVID-19 illness, hospitalizations, and death in Black and Hispanic communities are linked to several structural risk factors including living in crowded housing conditions, working in essential fields, Inconsistent access to health care, chronic health conditions, and chronic stress.

This specific health disparity is just one example of the striking effects of structural racism, years of distrust in healthcare, and lack of physical representation in the medical field on healthcare outcomes in this country. What is more alarming, is that even with the availability of a safe and effective vaccine, the historical pretext of racism in healthcare will delay and prohibit mass vaccination among many vulnerable minority populations. In a recent Kaiser Family Foundation poll, half of Non-Hispanic Black adults are not planning to take a coronavirus vaccine once one becomes available, even if scientists declare it safe and if it is available free of cost [2]. Among Non-Hispanic Black adults who say they are not planning to get a vaccine, nearly 40% cite safety concerns, including that it will be too new and assume insufficient testing [2]. Another 35% attributed their concerns to a general lack of trust or have doubts about the government or the health care system [2].

If we ever hope to get back to some sense of normalcy, herd immunity secondary to general vaccination needs to be the utmost priority among healthcare professionals. Overcoming the understandable barriers of distrust that exist in the minority community will not happen overnight. However, consistent efforts to understand, relate, and effectively communicate with patients of color can slowly help to assuage fears about vaccinations and create positive relationships between the healthcare system and the most vulnerable communities that are often ignored.

So I ask the question, what can you do as a healthcare provider to better understand and address these hurdles and to help encourage acceptance of the COVID-19 vaccination?

References

Rodriguez F, Solomon N, de Lemos JA, Das SR, Morrow DA, Bradley Smet al. Racial and Ethnic Differences in Presentation and Outcomes for Patients Hospitalized with COVID-19: Findings from the American Heart Association’s COVID-19 Cardiovascular Disease Registry. Circulation. 2020 Nov 17. Doi: 10.1161/CIRCULATIONAHA.120.052278. Epub ahead of print.
Hamel, L., Muñana, C., Artiga, S. and Brodie, M., 2020. KFF/The Undefeated Survey On Race And Health. [online] Kaiser Family Foundation. Available at: <https://www.kff.org/racial-equity-and-health-policy/report/kff-the-undefeated-survey-on-race-and-health/> [Accessed 16 December 2020].