Areas with Greater Socioeconomic Distress and Black or Hispanic Patients Get Less TAVR

Transcatheter aortic valve replacement (TAVR) both lengthens and improves the quality of life in patients with severe symptomatic aortic stenosis. Researchers found race, ethnicity, and socioeconomic based disparities in the rates of this life-sustaining therapy1.

Nathan et al. used Medicare claims data from 2012 through 2018 to study the association between zip code-level racial, ethnic, and socioeconomic composition and rates of TAVR performed. The number of TAVR procedures performed was lower in zip codes with lower median household income, greater proportion of patient who were dually eligible for Medicaid services, and lower overall economic well-being as determined by the Distressed Communities Index score. In addition, fewer TAVRs were performed in areas with higher proportions of patients of Black race and Hispanic ethnicity, regardless of socioeconomic markers, age, and clinical comorbidities.

Rapid advances in transcatheter heart valve interventions (THVI) have been revolutionary in the care of patients with valvular heart disease and technology continues to evolve at a dizzying pace2. Clinical uptake of proven devices has been fierce with several newer technologies at various stages of development and investigation. The evolution of transcatheter technologies and accumulation of relevant data have been so rapid that there has been a call for the creation of a “Heart Valve Collaboratory” to guide and arbitrate heart valve device innovations and research3.

However, the promise of THVIs to improve quality and longevity of life may be unequally distributed. The findings by Nathan et al. certainly seem to suggest that there is less TAVR to go around for minorities and the impoverished. The reasons for these results are not clear. A biologic basis for race-based differences in TAVR rates is plausible and effort into defining aortic stenosis natural history in different populations is warranted. However, race is a social construct and so causes for unequal access to TAVR very likely span beyond genetics alone.

According to the editorial by Dr. Clyde Yancy and Dr. Ajay Kirtane4: “…disentangling race from the entirety of the social construct is a complex and uncertain exercise. Is it possible that there are race-based biases impacting TAVR at the patient level? Yes. Is it proven? No. Equity in access to care and completeness of clinical assessment, including even a careful physical examination, also come into play when assessing disparities in a ‘downstream’ procedure such as TAVR.”

As an interventional and structural fellow, the unbridled innovations in transcatheter therapies are frankly exhilarating. But the notion of unequal access based on race, ethnicity, and social determinants of health should give us pause. It is a calling to redouble our efforts to study the underpinnings of such findings with the goal to extend the promise of THVIs to all.