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Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA is tenured Associate Professor of Medicine at Indiana University, Division of Cardiology, and advanced heart failure transplant cardiologist with the Advanced Heart Failure, Mechanical Circulatory Support and Cardiac Transplantation Team at Indiana University Health.

Welcome back to this month’s MedscapeLIVE! Cardiology E-News. This month I speak with Dr. Khadijah Breathett, tenured Associate Professor of Medicine at Indiana University, Division of Cardiology, and advanced heart failure transplant cardiologist with the Advanced Heart Failure, Mechanical Circulatory Support and Cardiac Transplantation Team at Indiana University Health. A cardiologist with specialized clinical and research training in heart failure and transplant, Dr. Breathett prioritizes providing evidence-based care and shared decision-making in her clinic. She co-authored the 2021 Update to the 2017 American College of Cardiology Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment. As an advanced heart failure and transplant cardiologist, her clinical work focuses on the prevention and treatment of the advanced heart disease including longitudinal heart transplantation and ventricular assist device care. We discussed:

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. 

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
  • View Faculty & Agenda: https://www.heartofcardio.com/agenda

Thank you to Dr. Breathett for his 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

Colleen: Coming up on two years since the publication of your article, Racial and ethnic disparities in heart failure: current state and future directions, let’s discuss what has been accomplished since this publication. Have “strategic and earnest interventions considering social and structural determinants of health” been developed? Is everybody doing as much as they can be? (Industry, medical associations, hospitals) 

Dr. Breathett: Thank you. It was great to collaborate on that paper with another leader in cardiovascular equity initiatives, Dr. Sabra Lewsey. I think that many remain interested in identifying how their practice of medicine can be improved to address inequities, but there is discomfort with change or change that has a monetary cost. The latest AHA/ACC/HFSA Heart Failure Guidelines now has a Class I recommendation to perform risk assessments and use multidisciplinary strategies to address disparities. Furthermore, there is a Class I recommendation to monitor and address disparities at both a practice and healthcare system level. I applaud this addition to the guidelines, but I think health policy changes will be needed to encourage implementation. If reimbursement for healthcare services is tied to providing high quality guidelines-based care, the needle may be pushed closer towards equity. Additional supportive strategies may include hospital-based awards and accreditation that require meeting equity guidelines or demonstrating changes to achieve equity. 

To avoid harming hospitals centered in lower resource communities, greater financial benefit/support could be offered to hospitals that have larger equity gaps to cover. Using strategies informed by patient leaders and stakeholders may identify the best methods to achieve lasting change in cardiovascular care delivery.

You recently published an editorial comment, U.S. Heart Transplantation Allocation: Injustice in Complacency, in JACC: Heart Failure. This was a comment on the article Race and Socioeconomic Bias in Pediatric Cardiac Transplantation. What was your comment’s main takeaway?

Dr. Breathett: Dr. Shahnawaz Amdani and team did excellent work trying to understand how bias may impact the allocation process for minoritized racial and ethnic children and children from families with fewer economic resources. It is saddening to see the similarities with adult allocation where we have found that patient race is associated with allocation of advanced heart failure therapies.  This paper and increasing number of others’ works have highlighted why we need to reexamine the process of allocating life-saving therapies to patients.  

Does the process of listing for heart transplantation need an update?

Dr. Breathett: My work has focused on identifying the mechanistic causes of disparities in cardiovascular care delivery. In advanced heart failure, it is clear that factors such as bias, subjectivity in assessment of social history, and group dynamics have a major role in the healthcare team decision-making process (PMID: 31707940 , PMID: 32692370, PMID: 36846988). The U.S. transplantation system is undergoing multiple changes over the next year or two. As these changes take place, it is important to consider how they impact the patient populations that have consistently received inequitable care, minoritized racial and ethnic groups and groups with lower socioeconomic resources.  

In the past few weeks, I had the privilege to lead work to understand the mechanisms of allocation disparities. In this year’s Journal of American Heart Association Go Red Issue (https://www.ahajournals.org/doi/full/10.1161/JAHA.122.027701), we examined the allocation process over approximately a month at 4 academic centers to understand how group dynamics contribute to allocation decisions, using standardized metrics to assess challenging of groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation. We found that higher quality group dynamics were significantly associated with higher likelihood of offering advanced therapies to women.

In another recent paper in the American Journal of Transplantation (https://www.amjtransplant.org/article/S1600-6135(23)00348-9/fulltext), we tested an implementation strategy to address bias, subjectivity in social history assessments, and group dynamics as a pre-test/post-test study lasting over a year at a U.S. advanced heart failure center. We provided training on 1) bias reduction and antiracism skills adapted from Dr. Molly Carne’s Bias Reduction in Medicine study, 2) use of standardized numerical assessments for social history, and 3) group dynamics. We found signals of improvement in bias and group dynamics related to the trainings. Participants felt that the strategy was more objective and equitable than current practice and feasible to employ. In whole, these mechanistic and feasibility studies contributed to the national study, SOCIAL HF (https://clinicaltrials.gov/ct2/show/NCT05390411), that I am leading across 14 sites in the U.S. This national randomized controlled cluster trial/ hybrid implementation science type 2 study seeks to improve allocation of advanced heart failure therapies to minoritized racial and ethnic group as and women. In a few more years, we will learn how these strategies impact allocation. 

What is a new treatment modality that excites you as an advanced heart failure and transplant cardiologist?

Dr. Breathett: I am thrilled that we have so many new life-saving treatments to offer patients with heart failure including heart failure with preserved ejection fraction. I am concerned that our U.S. healthcare system struggles with offering these new and old therapies systematically to patients that need them, particularly minoritized racial and ethnic groups and women. 

What has been the most impactful clinical advancement in the last decade as it pertains to your care of patients?

Dr. Breathett: Time will tell, but I think the class I recommendation to address disparities in the 2022 AHA/ACC/HFSA heart failure guidelines may be the beginning of impactful change in healthcare delivery in the U.S. I have concerns about implementation as described above.

What can be done to dismantle structural discrimination in fellowship recruitment in cardiology?

Dr. Breathett: Drs. Amber Johnson, Anezi Uzendu, Norissa Haynes, and Quinn Capers have led papers that describe tactics to reduce discrimination in cardiology fellowship (PMID: 34125564, PMID: 34037303, PMID: 36876741, PMID: 36603043). Successful tactics defined by these leaders include evidence-based bias reduction and anti-racism training, and merit-based assessments of leadership potential and health equity advocacy.

The Pulse

Circulation: Cardiovascular Intervention: Ischemia in Anomalous Aortic Origin of a Right Coronary Artery: Large Pediatric Cohort Medium-Term Outcomes


JAMA Cardiology: Association of Left Atrial Strain With Ischemic Stroke Risk in Older Adults


Cardiology News: Stroke scale cutoff might not be ideal guide for ordering CTA and detecting large vessel occlusions


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


JACC Original Investigation: Influence of Cardiac Remodeling on Clinical Outcomes in Patients With Aortic Regurgitation


NEJM Review Article: Dietary Sodium Restriction in Patients with Heart Failure


Medical Intelligence Quiz: Cardiac Resynchronization Therapy