The Impact Of Race And Ethnicity On Clinical Outcomes In Patients With Heart Failure(On Behalf Of The Guide-IT Steering Committee)

Abstract

Introduction Black and Hispanic patients (pts) with heart failure (HF) are under-represented in clinical trials. Thus, it has been challenging to understand the impact of race and/or ethnicity on clinical outcomes and responsiveness to treatment in pts with HF. Hypothesis The data in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in HF) trial was used to explore racial and ethnic differences in clinical outcomes. Pts were included who were event-free at 90 days and had data on attainment of guideline-directed triple therapy (GDMT, defined as greater than 50% target dose of beta-blocker, ACEI or ARB, and any MRA dose) or target NT-proBNP ≤ 1000 pg/mL. We postulated that Black pts would have worse clinical outcomes than non-Black pts, and that Hispanic pts would have worse outcomes than non-Hispanic pts. Methods Cox proportional hazards models were used to estimate the impact of race and ethnicity on mortality and HF hospitalization. These models accounted for 3-month achievement of GDMT or target NT-proBNP, as well as previously identified prognostic characteristics. Results Of the 733 patients included, 35% were Black and 6% were Hispanic. Black pts were younger, had more co-morbidities, lower EF, and higher NYHA class vs. non-Black pts. After accounting for GDMT attainment, Black pts were at a higher risk than non-Black pts for HF hospitalization (HR=1.97, 95% CI = 1.41-2.77, p < 0.0001), but not mortality (HR = 0.70, 95% CI = 0.39-1.26, p = 0.23) (Figures 1A-1B). Hispanic pts trended towards a higher risk than non-Hispanic pts for HF hospitalization (HR=1.83, 95% CI = 0.82-4.08, p = 0.14), but not for death (HR = 0.61, 95% CI = 0.18-2.09, p = 0.43) (Figures 1C-1D). Similar patterns were observed when accounting for target NT-proBNP. Estimated effects on mortality were limited by the low mortality rate (14%). Conclusion After adjusting for GDMT or target NT-proBNP attainment, as well as prognostic characteristics, Black HF pts had a higher risk of HF hospitalization than non-Black pts. There was also a trend for higher HF hospitalization risk for Hispanic pts compared to non-Hispanic pts . Mortality results were indeterminate, but point estimates did not support an excess mortality risk for Black or Hispanic pts. Black and Hispanic patients (pts) with heart failure (HF) are under-represented in clinical trials. Thus, it has been challenging to understand the impact of race and/or ethnicity on clinical outcomes and responsiveness to treatment in pts with HF. The data in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in HF) trial was used to explore racial and ethnic differences in clinical outcomes. Pts were included who were event-free at 90 days and had data on attainment of guideline-directed triple therapy (GDMT, defined as greater than 50% target dose of beta-blocker, ACEI or ARB, and any MRA dose) or target NT-proBNP ≤ 1000 pg/mL. We postulated that Black pts would have worse clinical outcomes than non-Black pts, and that Hispanic pts would have worse outcomes than non-Hispanic pts. Cox proportional hazards models were used to estimate the impact of race and ethnicity on mortality and HF hospitalization. These models accounted for 3-month achievement of GDMT or target NT-proBNP, as well as previously identified prognostic characteristics. Of the 733 patients included, 35% were Black and 6% were Hispanic. Black pts were younger, had more co-morbidities, lower EF, and higher NYHA class vs. non-Black pts. After accounting for GDMT attainment, Black pts were at a higher risk than non-Black pts for HF hospitalization (HR=1.97, 95% CI = 1.41-2.77, p < 0.0001), but not mortality (HR = 0.70, 95% CI = 0.39-1.26, p = 0.23) (Figures 1A-1B). Hispanic pts trended towards a higher risk than non-Hispanic pts for HF hospitalization (HR=1.83, 95% CI = 0.82-4.08, p = 0.14), but not for death (HR = 0.61, 95% CI = 0.18-2.09, p = 0.43) (Figures 1C-1D). Similar patterns were observed when accounting for target NT-proBNP. Estimated effects on mortality were limited by the low mortality rate (14%). After adjusting for GDMT or target NT-proBNP attainment, as well as prognostic characteristics, Black HF pts had a higher risk of HF hospitalization than non-Black pts. There was also a trend for higher HF hospitalization risk for Hispanic pts compared to non-Hispanic pts . Mortality results were indeterminate, but point estimates did not support an excess mortality risk for Black or Hispanic pts.