https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30569-X.pdf

Structural racism and health inequities in the USA: evidence and interventions

Background Dabigatran is an oral direct thrombin inhibitor that has been shown to be an effective alternative to warfarin in patients with atrial fibrillation. We evaluated the use of dabigatran in patients with mechanical heart valves. Methods In this phase 2 dose-validation study, we studied two populations of patients: those who had undergone aortic- or mitral-valve replacement within the past 7 days and those who had undergone such replacement at least 3 months earlier. Patients were randomly assigned in a 2:1 ratio to receive either dabigatran or warfarin. The selection of the initial dabigatran dose (150, 220, or 300 mg twice daily) was based on kidney function. Doses were adjusted to obtain a trough plasma level of at least 50 ng per milliliter. The warfarin dose was adjusted to obtain an international normalized ratio of 2 to 3 or 2.5 to 3.5 on the basis of thromboembolic risk. The primary end point was the trough plasma level of dabigatran. Results The trial was terminated prematurely after the e...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1300615

Dabigatran versus Warfarin in Patients with Mechanical Heart Valves

Recent work has emphasized the benefits of patient–physician concordance on clinical care outcomes for underrepresented minorities, arguing it can ameliorate outgroup biases, boost communication, and increase trust. We explore concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn–physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. We find no significant improvement in maternal mortality when birthing mothers share race with their physician.

https://www.pnas.org/content/pnas/117/35/21194.full.pdf

Physician-patient racial concordance and disparities in birthing mortality for newborns.

Inequality and the health-care system in the USA

Since the World Health Organization launched its commission on the social determinants of health (SDOH) over a decade ago, a large body of research has proven that social determinants-defined as the conditions in which people are born, grow, live, work, and age-are significant drivers of disease risk and susceptibility within clinical care and public health systems. Unfortunately, the term has lost meaning within systems of care because of misuse and lack of context. As many disparate health outcomes remain, including higher risk of maternal mortality among Black women, a deeper understanding of the SDOH-and what forces underlie their distribution-is needed. In this article, we will expand our review of social determinants of maternal health to include the terms "structural determinants of health" and "root causes of inequities" as we assess the literature on this topic. We hypothesize that the addition of structural determinants and root causes will identify racism as a cause of inequities in maternal health outcomes, as many of the social and political structures and policies in the United States were born out of racism, classism, and gender oppression. We will conclude with proposed practice and policy solutions to end inequities in maternal health outcomes.

/pdf/social-and-structural-determinants-of-health-inequities-in-4z7552qhit.pdf

Social and Structural Determinants of Health Inequities in Maternal Health

Structural racism leads to increased rates of premature death and reduced levels of overall health and well-being — an epidemic affecting our whole society. As clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism.

/pdf/structural-racism-and-supporting-black-lives-the-role-of-2hwn87d69u.pdf

Structural Racism and Supporting Black Lives — The Role of Health Professionals

In the wake of George Floyd’s public execution, uprisings have ignited in cities throughout the United States The words “I can’t breathe” hang heavy in the air Black people cannot breathe because we are currently battling at least two public health emergencies

Stolen Breaths

Background: Mechanical heart valve replacement is an absolute indication for anticoagulation. We report our experience comparing dabigatran to warfarin as thromboembolic prophylaxis after mechanical mitral valve replacement in the swine model. Methods: Nineteen swine underwent mitral valve replacement with a regulatory approved, 27 mm mechanical valve. Two control groups consisted of three animals receiving no anticoagulation and five animals receiving warfarin (5 mg once a day [QD], adjusted to maintain international normalized ratio [INR] from 2.0 to 2.5). The experimental group consisted of 11 animals receiving dabigatran (20 mg/kg twice a day [BID]). The study period was 90 days. The primary outcome was animal mortality; secondary outcomes included presence of thrombus and bleeding complications. Results: The experimental group had four full-term survivors (40.0%); there were no full-term survivors in either control group. The average length of survival was 50.3 days in the experimental group ...

Dabigatran versus warfarin after mechanical mitral valve replacement in the swine model

Structural racism is a fundamental cause of racial inequities in health in the United States. Structural racism is manifested in inequality in the criminal justice system; de facto segregation in education, health care, and housing; and ineffective and disproportionately violent policing and economic disenfranchisement in communities of color. The inequality that Black people and communities of color face is the direct result of centuries of public policy that made Black and Brown skin a liability. The United States is now in an unprecedented moment in its history with a new administration that explicitly states, "The moment has come for our nation to deal with systemic racism . . . and to deal with the denial of the promise of this nation-to so many." The opportunities for creating innovative and bold policy must reflect the urgency of the moment and seek to dismantle the systems of oppression that have for far too long left the American promise unfulfilled. The policy suggestions made by the authors of this article speak to the structural targets needed for dismantling some of the many manifestations of structural racism so as to achieve health equity.

Fighting for America's Paradise: The Struggle against Structural Racism.

Background: Cardiac allograft vasculopathy (CAV) is a major complication after heart transplantation, requiring frequent surveillance angiography. Though cardiac angiography is the gold standard, it is insensitive in detecting transplant vasculopathy and invasive. Perfusion MRI provides a noninvasive alternative and possibly a useful modality for studying CAV. We sought to compare the accuracy of qualitative perfusion MRI to coronary angiography in detecting CAV. Methods: A retrospective analysis was performed in 68 heart transplant recipients who had simultaneous surveillance cardiac MRI and coronary angiogram and who underwent transplantation between 2000 and 2007. We compared results of qualitative MRI to those of the cardiac angiogram. Sensitivity and specificity of MR were calculated. Results: Sixty-eight patients underwent both cardiac MRI and coronary angiogram. 73.5% were male; mean age was 45.37 ± 14 years. Mean duration of heart transplantation was 7.9 ± 5.2 years. The mean ejection fraction was 55% in the patients without CAV and 57.4% in those with CAV. There were 48 normal and 24 abnormal MRI studies. The overall sensitivity was 41% and specificity was 74%. Conclusions: Qualitative assessment of perfusion cardiac MR has low sensitivity and moderate specificity for detecting CAV. The sensitivity of MRI was slightly improved with severity of disease. Cardiol Res. 2011;2(6):282-287 doi: https://doi.org/10.4021/cr105w

/pdf/qualitative-perfusion-cardiac-magnetic-resonance-imaging-33frgt9lsy.pdf

Eduardo M. Medina

Papers

Structural Racism and Supporting Black Lives — The Role of Health Professionals

Stolen Breaths

Dabigatran versus warfarin after mechanical mitral valve replacement in the swine model

Fighting for America's Paradise: The Struggle against Structural Racism.

Qualitative Perfusion Cardiac Magnetic Resonance Imaging Lacks Sensitivity in Detecting Cardiac Allograft Vasculopathy