Clyde Yancy, MD: Addressing Inequities in Heart Failure

Clyde Yancy, MD
Courtesy: Twitter

At the 2022 annual meeting of the American College of Cardiology (ACC), the release of heart failure guidelines with endorsement from the ACC, American Heart Association, and Heart Failure Society of America stole the show. The first US guidelines to endorse SGLT2 inhibitors in the care of heart failure with preserved ejection fraction, the guidelines ushered in a new era in management of heart failure.

However, despite the introduction of this new era in care, what the guidelines were not able to do was eliminate the systemic barriers and inequities which have been plaguing the field for decades. The ongoing presence of these inequities were the subject of the Kanu and Docey Chatterjee Keynote at the ACC 2023 Annual Scientific Session Together With the World Congress of Cardiology. Named in honor of the late Kanu Chatterjee, MBBS, and his wife Docey Edwards Chatterjee, this year’s keynote address is set to be by Clyde Yancy, MD, chief of cardiology at Northwestern University Feinberg School of Medicine, who approached the address with the intent focusing on what he considers the “noble principles of medicine”, which he noted were central to both Kanu and Docey Chatterjee.

With an interest in addressing inequities in care in heart failure and learning more about Yancy’s perspectives on contemporary inequities in care, HCPLive sat down with Yancy ahead of his keynote address.

HCPLive: Can you discuss the impetus behind your keynote address and describe the impact of contemporary inequities in heart failure?

Clyde Yancy, MD: It is an opportunity, first of all, to re-instill in the mindset of everyone listening the values that Dr. Chatterjee brought forward to the medical community. In a world where we spend a lot of time with RVUs and margins and, most recently, with ChatGPT, it's refreshing to pause and think about a human being who brought the great characteristics of medicine to the profession and elevated it, with his focus on heart failure. That certainly aligns with my interests very well.

This is an opportunity to articulate what I think represents the best iteration of the guidelines we've had up to 2022. Specifically, we've never been able to offer patients this much hope, this much opportunity, this much prolongation of life, and reduction in symptoms as we can now. There is every rationale to endorse these new guidelines. Not to say that we've cured anything, but we're not just iteratively better, we are substantially better than we've been. So those are the first two important points, to revisit these noble principles of medicine that were held very tightly by Dr. Chatterjee, and to highlight and emphasize the importance of the current guidelines.

The third piece of this is to take on the challenge presented. How can we ensure that these therapies are administered in an equitable manner? We have to be very careful that we don't conflate the words "equal" and "equitable," because equitable means we're providing care that is specific to each patient to allow that patient to have the best possible health benefit.

Not every patient will need the same sort of emphasis, the same sort of focus, and most importantly, the same sort of resource material to assist in the attainment of these higher thresholds of care. But even more importantly, we have to recall and incorporate in our thinking that not every patient starts from the same place. We can't tell one patient to follow a heart-healthy diet and reduce their salt content without being aware that, in their community, that may not be possible. We can't tell someone to add an SGLT2 inhibitor to their regimen without recognizing that, for some people, even the co-pay may generate financial toxicity for their families. The equity piece is enormously important. We can't do all the research we've done to generate the evidence base we have and then articulate it as a guideline statement without recognizing that not every patient begins at the same place and has different resources to have the best possible outcome.

HCPLive: How do you, as a cardiologist, go about trying to address some of these issues and the systemic inequities that are causing some of these issues?

Yancy: There's an important frame shift in cardiovascular medicine now, meaning we can't just make the objective diagnosis, identify the marker of intervention, and deploy therapy and expect that to be sufficient. We're now in a place where we need to realize that patients are so much more vulnerable, not so much to the traditional risk factors that we may especially continue to advocate, but in fact, they're more vulnerable to their social circumstances. Once we begin to think broadly, this is the frameshift. While we are concerned about obesity, hypertension, diabetes, smoking, poor diets, and physical inactivity, that portfolio sets up an incredible amount of cardiovascular disease. But there's another element in that portfolio. And that element is the social environment in which people live and function. If that environment is characterized by poor education, poor nutrition, housing density, poor economic opportunities, that will have a health impact.

Here's a critical piece, and this is a piece that has not been a part of our mindset. When I say "our," I mean our collective mindset in the cardiovascular leadership professional community. But the important concept is that public policy, even when seemingly distant from health, always has a health consequence. So, if we're talking about how to support schools, how to lead school boards, what about housing, what about public transportation, and how do we ensure that good jobs are available throughout our communities? These may not seem to be on the radar for primary care physicians, cardiologists, and other subspecialists. However, every one of those decisions has health consequences that will ultimately bring that patient to the primary care physician, cardiologist, and other subspecialists.

The frame shift is just an awareness that there is more than just the seminal risk factors that we have always embraced. It is this additional, other element that is experienced differently as a function of gender, sex, orality, urban populations, ethnicity, age, disability, and yes, race. These parameters constitute an increasingly larger part of our population. Therefore, we need to pay attention to all public policy because all public policy has a health consequence.