Analysis of NIS database shows racial disparities in atrial fibrillation outcomes in heart failure


atrial fibrillation

Using data from a large and “nationally representative” sample of the US population, a recent study is the first—the authors posit—to demonstrate racial differences in in-hospital outcomes after atrial fibrillation (AF) ablation in patients with heart failure (HF).

Published in JACC: Clinical Electrophysiology, lead author Siddharth Agarwal (Oklahoma Health Sciences Center, Oklahoma City, USA) and colleagues, position their research in opposition to the previously reported posthoc analysis of the CABANA trial, which contended that procedure-related adverse events were “infrequent” and had no significant variance between racial/ethnic minorities and non-minorities. The CABANA trial had stated that the prevalence of HF in the ablation group was 41.9% in minorities, verses 18.2% in non-minorities.

Although several studies have shown that in patients with HF, AF ablation produces better outcomes when compared with drug therapy alone, Agarwal et al note that, historically, racial/ethnic minorities have been “underrepresented” in clinical trials focused on AF management and treatment.

Included in their analysis, the study authors included all hospitalisations in patients 18 years of age and under, who had been admitted for AF ablation from 2016–2019 and were recorded in the national inpatient sample database (NIS).

A total of 61,110 patients were divided into cohorts based on racial/ethnic subgroups (white/Black/Hispanic/other). The data revealed 20,085 patients had heart failure with preserved ejection fraction (HFpEF), of whom there were 16,675 (81%) white, 1,735 (8.4%) Black, 1,090 (5.3%) Hispanic, and 585 (2.8%) other races.  The patients who had heart failure with reduced ejection fraction (HFrEF) numbered 41,025, of whom 30,440 (75.9%) were white, 5,660 (14.1%) Black, 2,460 (6.1%) Hispanic, and 1,510 (3.8%) other races.

When assessing the independent association of race and outcomes after multivariate adjustment, the researchers found that among those with HFpEF, Black patients had higher odds of in-hospital mortality, cardiovascular complications and longer length of stay, whereas Hispanic patients and those of other races had higher hospitalisation charges, compared to white patients.

In persons with HFrEF, those of other races had higher odds of in-hospital mortality, longer length of stay and higher hospitalisation charges, while Black patients had lower odds of vascular complications and longer length of stay compared to white patients.

Offering explanation for their findings, Agarwal et al point to a “[higher] burden” of comorbidities among the racial/ethnic minorities in their cohort, which may have influenced their results. The authors state that, although analyses were adjusted for, and independent of, these comorbidities, “unmeasured confounders” may still exist.

Additionally, Agarwal and colleagues note that “implicit bias” of the healthcare community may have also contributed to their results causing disparities, which, in turn, have caused delays in referral for AF ablation, leading to worse outcomes, the authors conclude.


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