Local physician roundtables don't usually make news or capture the attention of thousands of social media users. But a physician roundtable in California did just that, with a striking anecdotal example of how patients experience harm when provider biases aren't recognized.1 It can result in delayed diagnostic cardiac testing or worse —treatment delays or the absence of treatment and highlights the disparities in healthcare.
In the video (around timestamp 1:15:55) of the roundtable hosted by the California Nurses Association/National Nurses United and the Berkeley Center for Social Medicine, the physician explains a case in which a Black woman complained of chest pain when coughing. When that internist conducted an ECG, found evidence of STEMI, and requested catheterization while the patient was in the hospital for back pain, the physician was met with reluctance. The cardiologist only wanted to see the patient in an outpatient setting.
That interaction paints a picture of potential underlying biases that exist across the entire healthcare system, including in cardiology. Even when unintentional, bias can be harmful. This type of underlying and perhaps unconscious prejudice is not limited to treatment of African Americans. It is seen in cardiology—as well as other specialties—with other racial minorities like the Hispanic population, transgender individuals, and women, whose cardiac complaints may be different than those experienced by men, and thus potentially dismissed.2 These biases can lead to unequal care and sometimes worse patient outcomes.
A 2022 study published in JSCAI showed that Hispanic patients were found to undergo cardiac procedures less frequently and that they have greater delays in reperfusion, plus longer door-to-drug and door-to-balloon times compared with white patients.3 The same study showed that African Americans have a higher prevalence of NSTEMIs compared to other racial or ethnic groups, but the population was the least likely to undergo revascularization procedures compared to white and Hispanic populations.3
Understanding the Differences in Patient Risk
Not all populations have the same risk for heart disease. For example, African American cardiac patients experience higher rates of coronary heart disease (CHD) mortality (hazard ratios of 2.18 for men and 1.63 for women) than white patients, even though incidences do not vary between the two races overall. Importantly, the risk factors for African Americans are higher, which means they are more likely to have undetected CHD4 According to a review in the Journal of Electrocardiology, African Americans can also present differently on ECG, further requiring patient-based assessments inclusive of race and free of bias.5
Gender, including cisgender and transgender individuals, introduces not just issues with bias and inequity but also medical issues associated with those undergoing gender transition. Transgender people can have higher risk of stroke, hypertension, and other cardiovascular events compared to cisgender people. Hormonal treatment can bring additional cardiac risks, though researchers are not yet able to definitely conclude that the risk is caused by hormones versus other causes. A 2018 study exemplified this, showing that trans women had an elevated risk for heart attack compared to cisgender women, but uncertainty resides if the cause was the hormonal treatment or the sex assigned at birth. Transgender individuals also have higher risk for ischemic stroke after six years of hormonal treatments, compared with cisgender men and women. Hypertension is also a higher risk, especially after long-term hormone use.6,7
These and other factors demand a closer look into the mechanics and potential effects of bias in medicine. Literature related to such disparities is pouring in, with PubMed tracking exponential jumps in papers that include the term "racial bias" starting around 2011. When searching for "transgender health bias," the numbers are much smaller but with an exponential jump as well, starting in 2016.
To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.
How Biases Can Affect Patient Care
The disparities and discrimination that occurs is not just about disease onset, prevalence, and mortality. It also appears within care planning itself.
In situations of percutaneous coronary intervention, an African American is less likely to receive drug-eluting stents.8 Other research published in the Journal of the American College of Cardiology has shown that Hispanic patients experience longer delays in diagnosing STEMI and receiving reperfusion treatment compared to non-Hispanic whites, with the Hispanic population also experiencing less utilization of evidence-based discharge care.9 Fortunately, the study found that the Hispanic patients experience similar clinical outcomes compared to the non-Hispanic white counterparts.
These inequities take place even in outpatient settings, as indicated by care plans for matters as simple as cholesterol management. According to one study published in Current Atherosclerosis Reports, African American patients with dyslipidemia were 15% less likely to report being prescribed cholesterol-controlling drugs than white patients. For Hispanic patients, that number increased to 20%.10
Research published in the JAMA Network Open in 2020 has shown how biases may factor into clinical decision making. African American women were less likely to be offered timely advanced therapies and more likely to be judged by the way they looked and the perception of their support networks.11
Checking Inherent Biases with Neutral Tools
These patterns add troubling context to the ongoing dialogue around how to achieve equitable cardiac care without sex-based or other bias. But reaching parity can be particularly difficult when the underlying factors fueling prejudices are inherent and unintended—as the cardiologist referred to in the viral video may well have been demonstrating.
How can cardiologists check their own biases for the good of their patients? Systemic change starts with small steps and happens in iterations. These are a few strategies that may help:
- Advocate for increased representation of people of color in local and national clinical trials.
- Conduct informal day-to-day bias checks in the spirit of the roundtable video. Diligence can help preempt unintended prejudices before they impact patients.
- When making a medical decision, ask yourself if you would give the same advice if the person was a different gender or race.
- Consider self-assessments to identify possible biases that may be at play in your practice.
- Adapt your personal Hippocratic oath to be cognizant of the disparities in healthcare.
- Is your judgement being influenced by a patients' comorbidities?
ECG as an Impartial Tool
Putting biases aside, it's also worth noting these indications for an ECG. If patients experience these symptoms, readings are warranted:12
- Symptoms like palpitation, dizziness, chest pain, seizure, syncope, and cyanosis.
- Symptoms associated with heart disease such as tachycardia and bradycardia, plus clinical conditions like hypertension, hypotension, shock, or murmur.
- Preoperative and postoperative anesthesia monitoring.
As an example, ECG can be helpful when evaluating transgender patients to identify and mitigate any long-term effects of hormonal therapy. It can help detect waveform abnormalities that might be caused by myocardial infarction, venous thromboembolism, or ischemic stroke.
It's important to pay attention to comorbidities that could cause disparities in care. HIV-positive patients have been shown to have significantly longer QTc intervals versus the general population and a higher incidence of pathologic QTc intervals.13 Paying special attention to the QTc intervals on an ECG can make a difference and help inform clinicians when prescribing medications to HIV-positive patients.
We've learned a lot about how to treat COVID-19, originally thought of as a respiratory illness, and its impact on the cardiovascular system. In light of this, patients admitted to the hospital with the disease should receive a baseline ECG with consideration if a patient's symptoms are rapidly worsening or severe, or if there's a high risk of organ failure and permanent dysfunction. Given the present disparities in COVID-19 outcomes among people of color, extra diligence in this population is essential.
The diagnostic ECG is a helpful tool. It can noninvasively and quickly identify cardiac irregularities at the point of care, but it still is just a tool. Awareness and behavioral modifications feed into the quality of care just as much as equipment and therapies. Above all, an assessment of the whole patient is necessary, including but not limited to the increased prevalence of risk factors associated with race, gender, and pre-existing conditions.
Resources:
1. Beyond Identity: Building Collective Struggles for Racial and Health Justice. YouTube. March 22, 2018. https://www.youtube.com/watch?v=wjq_xgptEuo
2. Woodward M. Cardiovascular disease and the female disadvantage. International Journal of Environmental Research and Public Health. 2019;16(7):1165. https://doi.org/10.3390/ijerph16071165.
3. Srivastava, G, Alhuneafat, L, Jabri A, et al. Racial and ethnic disparities in acute coronary syndrome: a nationally representative sample. JSCAI. 2022;(6):100451. https://doi.org/10.1016/j.jscai.2022.100451
4. Carnethon MR, Pu, J, Howard G, et al. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation. 2017;136:e393–e423. https://doi.org/10.1161/CIR.0000000000000534
5. Walsh B, Macfarlane P, Prutkin JMet al. Distinctive ECG patterns in healthy black adults. Journal of Electrocardiology. 2019;(56):15-23. https://doi.org/10.1016/j.jelectrocard.2019.06.007.
6. Connelly PJ, Marie Freel E, Perry C, et al. Gender-affirming hormone therapy, vascular health and cardiovascular disease in transgender adults. Hypertension. 2019;74(6):1266-1274. https://doi.org/10.1161/HYPERTENSIONAHA.119.13080
7. Getahun D, Nash R, Flanders WD, et al. Cross-sex hormones and acute cardiovascular events in transgender persons. Annals of Internal Medicine. 2018;169(4):205. https://doi.org/10.7326/M17-2785
8. Gaglia MA, Shavelle DM, Tun H, et al. African-American patients are less likely to receive drug-eluting stents during percutaneous coronary intervention. Cardiovascular Revascularization Medicine. 2014;(4):214-8. https://doi.org/10.1016/j.carrev.2014.04.003.
9. Guzman LA, Li S, Wang TY, et al. Differences in treatment patterns and outcomes between Hispanics and non-Hispanic Whites treated for ST-segment elevation myocardial infarction. Journal of the American College of Cardiology. 2012;59(6):630-1. https://www.jacc.org/doi/full/10.1016/j.jacc.2011.10.882.
10. Leigh JA, Alvarez M, Rodriguez CJ. Ethnic minorities and coronary heart disease: an update and future directions. Current Atherosclerosis Reports. 2016; (2):9. 10.1007/s11883-016-0559-4.
11. Breathett K, Yee E, Pool N, et al. Association of gender and race with allocation of advanced heart failuretherapies. JAMA Network Open. 2020;3(7):e2011044. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2768394
12. Sattar Y, Chhabra L. Electrocardiogram. [Updated 2022 Jun 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls; 2022. https://www.ncbi.nlm.nih.gov/books/NBK549803/
13. Sani MU, Okeahialam BN. QTc interval prolongation in patients with HIV and AIDS. Journal of the National Medical Association. 2005; 97(12):1657-1661. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640718/
