Health Disparities in Aortic Stenosis: Closing the Treatment Gap

Wayne Batchelor, MD, is Director of Interventional Cardiology and Interventional Cardiology Research at the Inova Heart and Vascular Institute. He is board-certified in cardiovascular disease with added qualifications in interventional cardiology.

Aortic stenosis is one of the most common diseases affecting the heart valves. It’s life-threatening, but also highly treatable. Yet many people with aortic stenosis aren’t getting the treatment they need.

That’s the conclusion my colleagues and I reached in a paper published in the Journal of the American College of Cardiology. We found that underserved patients, including minorities and patients with poor access to care, aren’t being treated for aortic stenosis as often as they should be. The reasons for that are complex — but we’re already working on ways to close the gap and help all patients get the care they need.

Aortic Stenosis & Aortic Valve Replacement

Aortic stenosis affects the aortic valve, one of the major valves of the heart. It occurs when the valve stiffens, forcing the heart to work harder to pump blood to the body. The major symptoms are shortness of breath, chest pain, and lightheadedness or fainting, especially during physical activity.

Untreated, aortic stenosis can lead to heart failure. In the past, aortic valve replacement was done via open-heart surgery. Over the last decade, a new procedure known as transcatheter aortic valve replacement (TAVR) has made treatment less invasive and safer for more patients.

TAVR was a major breakthrough for treating aortic stenosis. Yet many people with aortic stenosis aren’t benefitting from this new treatment.

Heart Valve Disease Treatment Gaps

In our study, we found underserved minorities make up a disproportionately small percentage of the people receiving TAVR treatment. Underserved patients often include racial/ethnic minorities such as African Americans and Hispanics, patients with lower socioeconomic status and poor access to healthcare, and people living in rural areas far from TAVR centers.

The disparities exist at every step from diagnosis to treatment. Underserved patients with aortic stenosis are less likely to be diagnosed in the first place. Those who do are less likely to be referred to a heart surgeon or a cardiologist. And even if they see a specialist, they are still less likely to get surgical aortic valve replacement or a TAVR procedure.

 The reasons for this are complex. We found a long list of barriers, in three key areas:

• Patient-related factors. These include things like race/ethnicity, disease awareness, access to care, insurance status, rural location, socioeconomic factors, health insurance status, cultural beliefs and preferences, and mistrust of healthcare systems. 
• Disease-related factors. These factors include elements such as the symptoms a patient exhibits, the severity of his or her disease, whether he or she has other co-existing heart valve diseases, and whether he or she has other non-heart-related diseases and illnesses.
• Healthcare/system factors. Other factors are related to the healthcare system itself, including bias in who is referred for diagnosis and treatment, cultural or language barriers, and regional access to treatment centers.

Added together, these factors make it harder for underserved patients to get the care they need.

Heart Health: What Patients Can Do

There are things patients can do to take charge of their heart health, regardless of their race/ethnicity, socioeconomic status or geographic location:

• If you experience shortness of breath and fatigue when you’re active, don’t assume it’s just a normal part of getting older. These symptoms could indicate a heart valve disease — which is extremely treatable. But it’s important to get diagnosed and treated as soon as possible.
• Educate yourself on the signs of heart valve disease and other heart problems. Check out Inova’s patient and community education and classes, or look for information from reputable sources such as the American College of Cardiology and the American Heart Association.
• If you are concerned about your heart symptoms, talk to your doctor and ask if you should get an echocardiogram. This test isn’t expensive, and it is key for diagnosing aortic stenosis.

Addressing Health Disparities

While it’s always important for patients to be their own advocates, they can’t do this alone. In our paper, we recommend four ways healthcare systems can improve care:

1. Collect more data to gather further insights into treatment biases.
2. Ensure heart valve treatment teams are trained to communicate in ways that respect the patient’s language and culture.
3. Improve patient education and access to care.
4. Change research paradigms to include more patients from underserved groups.

At Inova, we’re taking action in a number of ways, including:

• Raising awareness of treatment disparities with the many specialists who work in our heart valve clinic
• Working with translators and family members to make sure patients understand our diagnostic and treatment recommendations and have all their questions answered  
• Educating the public, including our surrounding community, about heart disease symptoms through lectures and other educational activities
• Tracking data to better understand treatment disparities and spot areas where we can improve patient care
• Planning future outreach efforts to reach patients in underserved areas

Aortic stenosis is a deadly disease, but it’s also a highly treatable one. At Inova, we’re committed to making sure all patients have access to lifesaving treatment for valve disease — regardless of where they live, what they look like, or what language they speak.

Find an Inova heart specialist and learn more about the award-winning doctors at the Inova Heart and Vascular Institute. 

Additional resource

As many as 11 million Americans have heart valve disease (HVD), but only 3 out of 4 American know little to nothing about HVD. Learn more about valve disease.