social justice – The Early Career Voice

In a year wrought with challenges spanning social, political, and healthcare spheres, one issue has risen to the forefront of our collective consciousness. Structural racism.

What is structural racism? A recently published presidential advisory from the American Heart Association states that “structural racism refers to the normalization and legitimization of an array of dynamics–historical, cultural, institutional and interpersonal–that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color.”

The planning committee for this year’s AHA Scientific Sessions took it upon themselves to address the presence of structural racism in Cardiology with a comprehensive series of lectures and discussions on the topic. The sessions kicked off on Friday, November 13^th with an awe-inspiring fireside chat featuring legends in the education and treatment of cardiovascular disease, Drs. Eugene Braunwald and Nanette Wenger. The discussion was moderated by legends in their own right, Drs. Clyde Yancy and Robert Harrington.

“When I arrived in Atlanta in the early 1960s, racism was prevalent…and sadly, it continues more than half a century later” – Dr. Nanette Wenger

The morning continued with the main event session, “How to Use Behavioral Interventions to Advance Equity in Cardiovascular Health.” Drs. Keith Norris, Eberechukwu Onukwugha, and LaPrincess Brewer eloquently proposed solutions for tackling disparities in hypertension management and post-discharge care, as well as shared a bold new vision for cardiovascular health interventions to address disparities across the board.

“I am issuing a call for us, as an American Heart Association, community to integrate community-based interventions to promote cardiovascular health […] First, we must recognize the historical improprieties and wrongs in research, from events such as the Tuskegee syphilis study and the Henrietta Lacks cell line, which have led to a lingering mistrust of scientists and clinicians among racial and ethnic minority groups.” – Dr. LaPrincess Brewer

Arguably the main highlight of the morning was the AHA Fellows-in-Training session, titled “Racism in Medicine: What Medical Centers & Training Programs Can Do to be Antiracist.” This program sought to implore early career cardiologists to engage in the fight against structural racism, as well as provide trainees with a forum to learn more about racism in Medicine. The esteemed panelists, Drs. Clyde Yancy, Ileana Pina, and Michelle Albert led an incredible discussion with plenty of teaching points and actionable items to strengthen and support diversity, equity, and inclusion in medical training.

“It’s not about the number of people in the room or what they look like […] it’s about the diversity of thoughts in the room” – Dr. Clyde Yancy

This year’s AHA Scientific Sessions is off to a great start! Judging by the quality of programming on Day 1, there will be plenty more to write home about after this weekend.

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The American Heart Association Scientific Sessions kicked off this morning in everything but the usual fashion—socially distant, virtual, absent the normal red regalia and buzzing convention center. And yet, it felt as though the necessary distance created space for a kind and level of discussion and introspection I’ve never before experienced during a large scientific conference. In particular, the Opening Session set the stage for the day with a thoughtful and deliberate discussion of racial and gender inequity featuring the inimitable Drs. Nanette Wenger and Eugene Braunwald along with moderators Drs. Clyde Yancy and Robert Harrington. The session covered historical aspects of the fight for equity in medicine told from the experienced perspectives of Drs. Wenger and Braunwald, while recognizing how far we’ve come—and have yet to go—in realizing the promise of an equitable society and equitable healthcare. That the session was quickly followed by one on how best to use behavioral interventions to advance equity, and then another forum on how training programs can adopt antiracist behaviors and policies, demonstrated the depth of the commitment to address equity and disparities during this year’s Scientific Sessions.

I was, however, most enamored by the first late-breaking clinical trial presentation of the day, summarizing the results of the International Polycap Study 3 (TIPS-3) clinical trial, simultaneously published today in the New England Journal of Medicine.¹ In an introduction by Dr. Dorairaj Prabhakaran, it was immediately evident how TIPS-3, a clinical trial evaluating a polypill containing low-dose simvastatin, atenolol, hydrochlorothiazide, and ramipril, fit perfectly within the context of the broader discussions of equity and social justice that permeated the day. The polypill, after all, is less the new-tech that many of us have come to expect in late-breaking sessions, and more a study in improving access to care. Noting the enormous burden of cardiovascular disease (CVD) in low- and middle-income countries, and the marked inter-and intra-country disparities observed in cardiovascular outcomes, Dr. Prabhakaran set the stage for how the polypill was—when all is said and done—a strategy study with the goal of improving equity. He summarized this idea simply and eloquently, concluding that while “medicine is inherently reductionist… the solutions have to be holistic.”

The TIPS-3 study, subsequently presented by Drs. Salim Yusuf and Prem Pais, evaluated the effects of the polypill and primary prevention aspirin against placebo in a two-by-two factorial design within an intermediate-risk population without preexisting CVD. The trial recruited 5713 participants from more than nine countries including India, the Philippines, Colombia, Bangladesh, Canada, and Malaysia, among others. Participants were followed for more than 4.5 years for a primary outcome of major CVD (including cardiovascular death, non-fatal stroke, non-fatal myocardial infarction), heart failure, resuscitated cardiac arrest, or revascularization. Despite achieving lower-than-anticipated levels of blood pressure and LDL-cholesterol reduction (5.8 mmHg and 19 mg/dL, respectively in the polypill arm), the trial saw a 21% reduction in the primary outcome in the polypill arm when compared to placebo (HR 0.79; 95% confidence interval [CI], 0.63 to 1.00), and an even more impressive 31% reduction in the aspirin + polypill group (HR 0.69; CI, 0.50 to 0.97). Unsurprisingly, aspirin alone did not significantly reduce the incidence of cardiovascular events, though this finding does make the additive reduction in CV events in the polypill + aspirin arm more unusual. The benefit of treatment with polypill + aspirin was, moreover, seen early (within the first two years of the trial), and was evident despite relatively high rates of discontinuation of therapy in the follow-up, driven primarily by logistical challenges in obtaining therapies.

With these findings, TIPS-3 adds to the growing and consistent body of evidence from prior trials including HOPE-3² and PolyIran study³, demonstrating that polypills have the potential to impact both intermediate endpoints and cardiovascular outcomes in a primary prevention population. The potential of the strategy to impact cardiovascular disparities is apparent, but the true test of our commitment to health equity globally will be seen in whether we are able to translate such findings into meaningful programs and interventions in the coming years.

REFERENCE

Yusuf S, Joseph P, Dans A, et al. Polypill with or without Aspirin in Persons without Cardiovascular Disease. New England Journal of Medicine 2020.
Yusuf S, Bosch J, Dagenais G, et al. Cholesterol Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med. 2016;374(21):2021-2031.
Roshandel G, Khoshnia M, Poustchi H, et al. Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial. Lancet. 2019;394(10199):672-683.