Hot Topics with Dr. Alanna Morris

Dr. Alanna A. Morris is Associate Professor of Medicine, Department of Medicine, Emory University School of Medicine.

Welcome back to this month’s MedscapeLIVE! Cardiology E-News. This month I speak with Dr. Alanna Morris, Associate Professor of Medicine, Department of Medicine, Emory University School of Medicine. A cardiologist with specialized clinical and research training in heart failure and transplant, Dr. Morris’ research interests include studying the importance of non-modifiable risk factors such as race and gender that may contribute to excess disease in high-risk populations and identifying the role of biomarkers of oxidative stress (OS) and endothelial dysfunction in patients with heart failure with reduced ejection fraction (HFrEF). She also seeks to define race- and gender-based differences in these biochemical and vascular markers, and whether they contribute significantly to observed differences in HF morbidity and mortality. Finally, her research examines race- and gender-based differences in outcomes after heart transplantation and LVAD implantation. She co-authored the Circulation article, Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association, which we discussed in this interview. We also discussed:

What Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association major takeaways
Research on outcomes differences based on race-ethnicity and gender related to heart transplantation and LVAD implantation.
The conundrum of the financial burden on patients living with heart failure.
Her approach informing patients on long-term survival after heart transplantation, when racial disparities in outcomes exist.

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Also check out this issue’s Pulse, with articles from the Journal of the American Heart Association, Circulation, European Heart Journal, Journal of the American College of Cardiology, Cardiology News, and New England Journal of Medicine.

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Housekeeping: CME 2023—Add this to your calendar now and sign up for updates:

Going Back to the Heart of Cardiology Conference (4th Annual)

Saturday-Monday December 8-10, 2023; Anaheim, California

To register, click here!

Sessions 1-6: Cardiopulmonary Failure; Atherosclerosis and Thrombosis; and Cardiometabolic Disease; Electrical Failure; Valvular Disease: Special Topics in Cardiology

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Thank you to Dr. Morris for her time and expertise as faculty and in this interview. Don’t forget to register here for Medscape’s 2023 Going Back to the Heart of Cardiology conference for the best 2023 CME opportunity available! Please contact me at colleen@cmhadvisors.com with any comments and/or suggestions! –Colleen Hutchinson

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In your article in Circulation, titled Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association, what are the main guidance pearls regarding which patients should be referred to an advanced heart failure center (AHFC)?

Dr. Morris: We tried to highlight the clinical clues of worsening or advanced HF, based on symptoms, biomarkers, vital signs, echocardiographic parameters, and other factors that clinicians should recognize. One of the more common features that is often overlooked is patients who are repeatedly hospitalized for HF. Clinicians have implicit bias, and we know that we often attribute repeated hospitalizations to dietary or medication nonadherence, rather than recognizing that these patients are just sick and need a higher level of care. Black patients and women are more likely to suffer from clinicians’ bias. In this document, we really tried to highlight the clinical features of advanced HF that all clinicians should recognize, and we encourage referral for patients with features of advanced disease, even it might be “too early.” We also highlighted that advanced therapies like heart transplant and LVAD are not the only things an AHFC has to offer. In 2023, we are really lucky in that the armamentarium to treat HF includes multiple medical and device-based therapies, transcatheter valvular therapies, and increasing numbers of clinical trials. We want to ensure that all patients have access.

The financial burden on patients living with heart failure is real. What do you think needs to be done?

Dr. Morris: Patients with HF are at high risk for polypharmacy, not only because the guidelines tell us to use multiple drugs to treat the HF, but because most have other comorbid conditions that also require multiple drugs. While there are many new drugs that have tremendous impact on clinical outcomes, they are often unaffordable for patients because of high co-payments. We need the pharmaceutical industry and insurance payers to recognize the challenges our patients face accessing these beneficial therapies, and reduce or eliminate out-of-pocket costs to patients. Clinicians can’t prescribe drugs that our patients can’t afford if patients can’t take the drugs because they are unaffordable, and they can’t realize the clinical benefits.

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What is the research telling us about outcomes differences based on race-ethnicity and gender related to heart transplantation and LVAD implantation?

Dr. Morris: In general, women and patients from historically marginalized racial and ethnic groups are still underrepresented as candidates for these therapies. That is, in part, because these patients are less likely to be referred to cardiovascular specialists as compared to their male and White counterparts. Once they are referred, they are often sicker and further advanced in their disease trajectory. Once women receive advanced therapies for HF including transplant and LVAD, their outcomes appear to be similar, particularly with the newer generation LVAD. However, Black patients continue to have survival after heart transplant that is worse than all other racial and ethnic groups.

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What can be done to eliminate the factors contributing to these disparities?

Dr. Morris: We have to make sure that HF is recognized urgently, that all patients get appropriate guideline-directed medical therapy, and that patients who have worsening HF are referred to cardiovascular and/or advanced HF specialists. A recent paper showed us that women and Black patients are more likely to have their diagnosis of HF missed in the outpatient setting, resulting in them being more likely to be diagnosed with HF in the emergency room. Similarly, other papers have shown that women, and Black and Hispanic patients are less likely to be cared for by cardiovascular service lines when they are admitted to the hospital with acute HF, even though care by a cardiologist improves clinical outcomes. Again, we need to make timely diagnoses, recognize who has worsening disease, and make sure that all of those patients who are worsening have access to specialty care.

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How do you approach informing your patients on long-term survival after heart transplantation, when racial disparities in those outcomes exist?

Dr. Morris: Heart transplant is a gift, and I don’t know that I routinely inform patients about the disparities in outcomes as soon as they’ve been given that gift. I don’t want to take away any patient’s hope, particularly at a time when they are as optimistic and thankful as patients often are just after transplant. I think we all try to emphasize the importance of adherence and close follow-up. I think the onus is really on the scientific community. Because of the higher burden of HF among Black Americans, roughly 1 in 4 heart transplants in this country goes to a Black patient. As a scientific community, we need to improve and extend our research to understand why we don’t see better outcomes among these patients.

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The Pulse

Circulation: Cardiovascular Interventions: Coronary Microvascular Disease in Contemporary Clinical Practice

https://www.ahajournals.org/doi/abs/10.1161/CIRCINTERVENTIONS.122.012568

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JAMA Cardiology: Diagnostic and Prognostic Value of Stress Cardiovascular Magnetic Resonance Imaging in Patients With Known or Suspected Coronary Artery Disease

A Systematic Review and Meta-analysis

https://jamanetwork.com/journals/jamacardiology/article-abstract/2805949

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Cardiology News: Is ChatGPT a friend or foe of medical publishing?

https://www.mdedge.com/cardiology/article/263471/business-medicine/chatgpt-friend-or-foe-medical-publishing

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The 2023 4th Annual Going Back to the Heart of Cardiology:

https://na.eventscloud.com/website/36345/savethedate/

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JACC Original Investigation Editorial Comment: Disrupting the Definition of Heart Failure: A Rose by Any Other Name

https://www.sciencedirect.com/science/article/abs/pii/S0735109723053858

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