Good afternoon, friends. Thank you for joining us this afternoon as we delve down some actionable steps that we can take towards achieving health equity and arrhythmic care. I'm Dr. Linton Frazier, I'm an EP in Indiana PA. We have a fantastic group of presenters this afternoon, the first of which is Dr. Jonathan Crispin. All right. Thank you. Thank you for the introduction and the opportunity to talk to you all today about bridging the gap, addressing disparities in cardiac electrophysiology care. So certainly, obviously, we won't be able to touch on everything that has to do with this topic. And certainly, there's a lot of aspects to address. Over the next, you know, 10, 15 minutes, I will kind of focus on atrial fibrillation, which is the most common chronic arrhythmia there is in the world, kind of provide some data about some of the gaps that we have in care for patients with atrial fibrillation, and hopefully have some ideas about how we can bridge those gaps. So a number of epidemiological studies have highlighted the fact that, you know, whites compared to other racial groups seem to have a little bit higher incidence of atrial fibrillation. This is one such study from the UK Biobank, where white individuals weren't twice as likely to have atrial fibrillation. And we certainly know that there's certainly a genetic component to AFib. But the paradox relies on the fact that non-white individuals typically have more risk factors that are more commonly associated with atrial fibrillation, things like high blood pressure, diabetes, and heart failure. So why is it that, you know, those risk factors are a lot higher, but the incidence of atrial fibrillation appears to be a lot lower? And so is it because of genetic predispositions, or maybe it's just from under-detection of atrial fibrillation in these cohorts of individuals? Study trying to sort of address this question was from MESA, so MESA is a multi-ethnic study of atherosclerosis. Overall, it's about 6,000 patients, I think it's been going on for over 30 years now, so a prospective observational study. And then between 2016 and 2018, during one of their study visits, they did 14-day ambulatory ECD monitors for all patients. And so this cohort was about 1,500 patients out of that 6,000, average age of 74 years. Half of them were women, 41% white, 25% African-American. And what they found was that clinically detected atrial fibrillation, so just patients who were diagnosed with atrial fibrillation over the course of their usual clinical care, it did seem to kind of hold that African-Americans and Hispanics maybe have less atrial fibrillation compared to whites. But when they actually did look at the monitor itself, the ambulatory ECD monitor, this is over a 14-day period, they found that that difference didn't really exist. There were actually the same rates of atrial fibrillation between all the groups, suggesting at least in this cohort of individuals that it may not be that white individuals may have more atrial fibrillation, it's just possible that we're just not diagnosing atrial fibrillation appropriately in certain racial groups. And certainly this is not because of lack of symptoms. Certainly there are patients with atrial fibrillation who are asymptomatic. But this is data from the ORBIT-AF registry of 9,500 patients. And what the study also showed is that black patients compared to white and Hispanic patients actually have more symptoms associated with atrial fibrillation. More likely to have palpitations, more likely to have dyspnea with exertion, more likely to have fatigue. Now a lot of these are sort of individually sort of nonspecific, somebody comes to your clinic with these sort of nonspecific type of symptoms. If you're not attuned to atrial fibrillation, you may not be thinking about it. But this highlights the fact that they are very symptomatic with these when they do have atrial fibrillation, and it kind of warrants further investigation when they do present. And this certainly has really important clinical consequences. This is a study of 15,000 patients from AHRQ, of all these patients were diagnosed with atrial fibrillation. And what they found is that black patients compared to whites who have a diagnosis of AFib are more likely to have strokes, more likely to have heart failure, and more likely to die prematurely. And so, while this doesn't go into why this is the case, why is there these sort of disparities, it highlights the fact from these previous slides that you may be underdiagnosing atrial fibrillation in certain racial groups, you may not be attuned to the symptoms that they present with, and because of that there may be some important clinical serious consequences because of that. So, when we talk about equitable care for atrial fibrillation, I kind of have these sort of pillars, and one of these pillars, I think, is an important one, is just education. Education not only for healthcare providers, certainly in the EP world, we see AFib all the time, and we're kind of attuned to diagnosing and making diagnoses for AFib, but most of these individuals are coming to their primary care doctor, maybe even they have a cardiologist. And so, unless they're sort of educated about the signs and symptoms associated with atrial fibrillation, doing proper screening, it's not very common that people refer to me with like a 24-hour hold to monitor, well, 24 hours is probably not enough to detect proximal episodes of atrial fibrillation, so longer monitoring periods. But also, I think what's just as important is actually educating patients, patients about what is atrial fibrillation, you know, I think now we're seeing more and more commercials on TV for blood thinners and things like that, so people are more aware, they see their friends at dinner parties, oh, I have AFib and I got an ablation procedure, so I think that sort of patient awareness needs to be more prominent about the signs and symptoms associated with AFib. Similar to what we've been doing in the public health space for things like coronary disease or MIs or strokes, you know, you talk to anybody pretty much on the street, they'll tell you, oh, chest pain, or we're finding difficulties, this is a sign of something that's going on from a cardiovascular perspective, I think we need to do a better job in the AFib space. So it's been appreciated for, you know, over 50 years that AFib, one of the most serious consequences is strokes. You know, data I believe from the 1970s from Framingham Heart is where we kind of got that number of a five-fold increased risk for strokes with atrial fibrillation compared to those who don't have AFib. And we know that being on oral anticoagulants reduces your risk of stroke back down to a level of almost somebody who does not have atrial fibrillation. This was a study from the UK Biobank of patients with atrial fibrillation who are not on treatment with oral anticoagulants here in the blue line. And in patients who had atrial fibrillation but were on a blood thinner, their risk of stroke was similar to those who did not have atrial fibrillation. And similarly, all-cause mortality was significantly reduced amongst AFib patients who were on a blood thinner. Highlighting the fact that being on a blood thinner is really kind of a crucial first step for appropriate patients when they're diagnosed with atrial fibrillation. Unfortunately, at least historically, we haven't been doing a great job in terms of putting people on blood thinners. So this is a study of 2.4 million individuals from the Medicare Medicaid Service Claims Database. And what we're looking at are heat maps in terms of disparities of prescriptions for blood thinners across the country. And what they found was that black patients compared to white patients were less likely to be treated with a blood thinner. Even though the average CHAS VASc score for black patients' population was 5.3, the average for whites was 4.5, 56% of black patients were not prescribed a blood thinner. The biggest disparity was seen here in the southeast. And then amongst those who were prescribed a blood thinner, and certainly this is a little bit older data from 2016, most of them were prescribed Warfarin or vitamin K antagonists. In the next slide, I kind of highlight why that would be a potential big issue. And so they're not being treated, and those who were treated were less likely to be on a DOAC. Now, I'll be remiss to point to the fact that I think we were just doing a bad job for everyone, honestly, with putting people on blood thinners. Even amongst white individuals, once again, the average CHAS VASc for this population was 4.5 for the white individuals. You know, 47% of these people, patients, were not on a blood thinner. Similarly, this is data from the Northwestern Medicine Enterprise Data Warehouse. So this is 11,000 patients in the Chicago area. And similar to the previous study, they found that after adjusting for age, gender, income, insurance status, and stroke risk factors, you know, black patients were less likely to be put on a blood thinner, as well as Hispanic patients. And among those who were anti-coagulated, so they were prescribed a blood thinner, blacks and Hispanics were more likely to be prescribed a vitamin K antagonist over a DOAC. And in this study, so this is their data from this cohort, what they found is that amongst those who are prescribed a vitamin K antagonist here in the blue line, they are more likely to have strokes and thromboembolic events compared to those who are prescribed a DOAC. And so now you have sort of a couple of hits where you're less likely as a racial minority to be prescribed a blood thinner, and if you are prescribed a blood thinner, you're more likely, at least in this cohort, to be prescribed a vitamin K antagonist. And so your risk for strokes are just significantly higher compared to those who are white. And part of the reason for that may be the fact that they're just not having therapeutic INRs. So this is data from 180,000 patients from the VA. All these patients were diagnosed with atrial fibrillation, and what we find here is that the time in the therapeutic range was significantly lower amongst black patients compared to all other racial groups. Once again, this doesn't go into why this is happening, but amongst patients who were appropriately integrated, at least with a vitamin K antagonist, they were spending less time in the therapeutic range, so therefore not really getting the effect of the drug itself. So it's not all terrible bad news. So this is actually a study that was published just last year. What they're looking at is prescriptions for DOACs over time, blacks compared to whites. So here, navy are blacks. Here in orange is the white cohort. And so 15 years ago, there's certainly a big difference in terms of those who are prescribed DOACs, but it seems like over time, things have improved where there's really sort of no difference nowadays. And I think part of that has to do with the release of more current AHA, ACC, HRS guidelines where DOACs are given the preferred treatment option for blood thinners compared to vitamin K antagonists. So in terms of a second pillar, I think stroke prevention is sort of another sort of key area for us to target to provide more ethical care for people with AFib. Once a diagnosis is made, identifying what their stroke risk, based on their CHAZ-VASc, and prescribing appropriately anticoagulation to reduce their risk for stroke and other thromboembolic events. And in the last few minutes, I want to talk about how do we treat atrial fibrillation. So we focus on first diagnosis, then stroke prevention, and then once a diagnosis is made, how do you treat these sort of individuals? And so this is a study many of you are familiar with from 2020, the EAST-AFNet study. This is a randomized controlled trial of early rhythm control with primarily in this study antiarrhythmic drug therapy compared to rate control with the outcomes of death, stroke, heart failure, hospitalization, or acute coronary syndrome. In the study, authors found there was a 21% reduction in the primary composite endpoints with a 20% reduction in cardiovascular-related mortality, as well as a 35% reduction in strokes, highlighting the importance of rhythm control, particularly early rhythm control, to hopefully decrease the risk of these cardiovascular outcomes. But historically, we haven't been doing a great job in terms of ethical care about who gets rhythm control and who doesn't. So this was a study of 500,000 Medicare patients. And what they looked at was who got referred for catheter ablation, who underwent rhythm controlling medication. And not surprisingly, based on this data set, that black and Hispanic patients were less likely to be offered catheter ablation procedure and less likely to undergo any sort of rhythm controlling medication. And as we discussed in the previous slides, also less likely to be prescribed oral anticoagulants. Similar findings were seen from the Get With The Guidelines registry of 21,000 patients, where Asians here and blacks were less likely to undergo a cardioversion when they had persistent atrial fibrillation. And any rhythm control, black patients were less likely to undergo any rhythm control strategy compared to white individuals. Keep along with that sort of theme. This is more data from the Optum Clin Informatics Data Marge Socionomic Status Database, where they found that non-Hispanic blacks were 10% less likely to receive an antiarrhythmic drug for treatment of their AFib. And then once they were initiated, those who were initiated on a drug, they were more likely to have AFib-related hospitalizations, but were still 17% less likely to receive an ablation procedure compared to non-Hispanic whites. And putting it all together, this is a meta-analysis, which included 12 million patients, so a lot of patients, summarizing kind of all these sort of studies. And sort of just the common theme, when blacks compared to whites were less likely, 32% less likely to undergo a catheter ablation procedure, and 31% less likely to undergo a cardioversion, two important treatment options for the management of atrial fibrillation. And this is, you know, despite the fact that we actually have some pretty good data suggesting that blacks actually maybe do better with AFib ablation compared to some other groups. You know, certainly this is kind of a smaller cohort from the CABANA trial. So CABANA was a randomized clinical control trial comparing ablation procedure versus drug therapy for the initial management of atrial fibrillation. And we see here in the solid blue, these are patients who underwent drug therapy on a drug therapy arm. You know, they did a lot worse in terms of the composite end point compared to those who underwent catheter ablation. And so it's not like, you know, and so highlighting the fact that maybe we should be offering more first-line treatment, especially for, you know, non-white patients based on this data. So in summary, you know, certainly we could add a lot more pillars to this building. You know, just because of the time, you know, can address everything. But I do think, you know, to hopefully kind of, you know, bridge a gap, decrease some of the disparities, think education for patients, for healthcare providers to help improve in terms of the diagnosis of atrial fibrillation. You know, once again, once the diagnosis is made, make sure people are properly anticoagulated on blood thinners. And finally, you know, rhythm control, especially early rhythm control has been shown to really reduce morbidity and mortality associated with, or at least morbidity associated with atrial fibrillation. And then this is something that definitely should be offered to all of our patients to provide more equitable care. And I'll stop there. Thank you. Fantastic presentation, Dr. Crispin, expertly delivered. We'll hold questions for the final, well, after the final presentation. So next we have Dr. Temerisa from Texas Cardiac Arrhythmia, who will speak to us regarding disparities in cardiovascular electrophysiology care in older patients, Dr. Temerisa. All right. Thank you, everyone. Initially, we thought we might have only one or two people in the audience, so super excited that truly thank you for making time for this very important session. The topic assigned to me is older adults and what can we do or just talk about the gaps. Now initially when I was putting this talk together, I kind of thought, you know, why should we be talking about this? Because by no means I'm an expert in this area, but it's an important thing because of several reasons. I'll start off with a few slides on that. Aging baby boomer generation. So this is the United States Census data. Just if we can look at the aging nation graph, by 2034, for the first time in the U.S. history, older adults projected numbers are going to outnumber the children, and it's clearly shown in the bar graphs there. And most of us who are used to the population pyramids, you know, 1960, it's a century change. In 1960, if you look at it, the children are projected on the Y axis and a million of people on the X axis there. So the children are, you know, more in number, and as they get older, it becomes like a pyramid. By 2060, the projection is it's going to become a pillar from a pyramid, telling us that older patients, our population, are going to surpass the younger generation. So yes, we have older patients more and more. What about the disease burden that we all handle? I kind of, for this topic, I just fixed, pretty much focused on atrial fibrillation and the variables. Device data is there, too. Just to look at atrial fibrillation and the burden of the disease overall when you take age into the perspective, again, this is VITAL-AF, the Framingham Study, Rotterdam, and, you know, Puccini's, John's, you know, registry data. So AFib prevalence, just by age, it's 6.5% when someone is 65 to 69 years of age, and it increases by five times once they're over equivalent to 85 years in age. And what does that mean in simplistic numbers? Basically one-third of the individuals over the age of 85 will have, you know, prevalent AFib. Now looking at the counties and Medicare beneficiaries, and again, the older adults, I use, you know, they use 65 as the cutoff because of Medicare beneficiaries. Now just looking at this heat map, we can see that probably it's okay to say that half of the country has really higher incidence and prevalence, not incidence, but prevalence of AFib. Again, this is from CDC data. So the heat map, so the number of older adults are increasing, AFib burden is increasing by age, and healthcare hospitalization, and we know it's cardiac dysrhythmia, but we know the commonest arrhythmia that's contributing to this is AFib. Now that's, we know the burden now, let's talk about how we manage our patients. Most of us, you know, all of us in the real world use clinical trials to guide us with decision making, and this was published in BMJ 2024, kind of shows the population, U.S. prevalent population is projected in yellow bar, and the clinical trial population is projected in the blue bar, and as we can see, once a patient, you know, the age of 80, the number of people, clinical trial population is much lower when compared to the number of general population, and that goes, the gap is much higher once someone is over the age of 85. So when we manage these patients in the clinical setting, we start to think, you know, everything I use based upon the guidelines, am I really customizing to this patient I'm seeing who's 85, 86 year old? You know, we use the generalized data that we have. And I put in some studies here, East AFNET 4 trial, just looking at outcomes, AFib management outcomes by age-based. And the cutoff here was 75 years. There's no difference in quality of life, whether you ablate them or not ablate them. What about Cabana, which guides us a lot with the treatment management? They showed that, I have another slide on Cabana, just mean age of trial population that was enrolled is 68 years. Better quality of life with ablation, lower complication rates, even in older adults. And they also found that AFib is linked to cognitive decline. Ablation showed benefit, you know, from cognitive improvement with the ablation. Danish registry, more than 100,000 patients, 29% had increased risk of falls and syncope with antiarrhythmic medications. But most of the medications most commonly used was imidarone. And digoxin, we know increased mortality without any improvement in quality of life. So I just put these trials to just open a dialogue, how confused we can get as I was preparing this. So let's take a look at Cabana. Ablation is better than antiarrhythmic medications. And the p-value here is very significant. What about if you look at less than 65 years, 65 to 75 years, and more than or equal to 75 years? And the greatest benefit with catheter ablation was seen in less than 65 years. Modest benefit in 65 to 75. And they found that in over 75 years, there's trend towards harm with catheter ablation, even though it was not statistically significant. So when we are taking these patients to the lab, we are supposed to say, well, yeah, the complication rates are higher, but you're gonna have improvement in cognitive improvement, and probably you'll have benefit as far as your quality of life. What about the retrospective observational studies? And they showed lower death rates, better quality of life, and strokes with ablation, but the complications tend to be a bit higher. And Medicare beneficiaries here, more than 75 years of age, death within 30 days of the procedure occurred more frequently if someone was over the age of 75. So the take-home point from all these is, yes, there's benefit in quality of life, cognitive improvement with ablation, but complication rates potentially are higher. What about the left atrial appendage occluders? We don't have really age-dependent data. If any updates out there, I'm willing to, you know, I'm really open to dialogue here, but we don't have age-dependent outcomes. So we use the same thing like we use for every other patient, even our 40-year-old patient, we tell them the same thing. But we are still waiting on DOACs, and of course, comparative data with left atrial appendage occluders, and we need more data now. Just what are the gaps? I think we all are aware that we don't have randomized controlled trials looking at age alone when we are managing this older population. And there's selection bias and issue of appropriate patient selection because of that. And inadequate treatment showing about anticoagulation. I thought this was better than this when I was preparing for the talk. I realized by putting it together, 50% of the population over the age of 75 years were not anticoagulated. That's a lot. Half of the population, they're not anticoagulated with no documented contraindication in almost 45% of the patients. And which means that we are leaving that 50% of the population without any reason for contraindication just because age somehow becomes a barrier to effective treatment, leaving them exposed to strokes. And now we use the charts to vascular risk score. It's great, but maybe we need to move away. We don't know in those specific intersectional. Again, we are talking about disparities in this session here. There's so much of intersectionality. What about an African American older woman? What are their risks? I don't know. So should we be moving away or building upon, I should say, on charts to vascular risk score, Garfield AF calculators or Markov's decision, which was used in our heart rhythm guidelines. And I'll touch a few points on falls and frailty because in the clinical practice, I think that's the reason we don't prescribe anticoagulants to our patients because we are very fearful that they're frail or they might fall. And what about falls? Falls alone rarely justify avoiding anticoagulation. And older adults would need to fall 100 times annually before we say you can't take an anticoagulant. And looking at 295 falls for warfarin is a contraindication. So it takes a lot of falls before we say you can't take an anticoagulant. More than 45 for rivaroxavine. And I listed the other numbers. Yes, bleeding risks are there, but stroke risks are much higher. So falls alone are not a good reason not to prescribe our older patients with anticoagulants. And what about DOACs versus warfarin? Large database studies and some looking at this basically showed us that DOACs actually are better than the warfarin from bleeding risk standpoint. And then let's say we take these patients to the clinic and we prescribe the DOACs, again, older patients. And a lot of us, we see that they're unable to afford. Cost is very high. And the cognitive dysfunction is very important because sometimes they might overtake the medication, undertake it, and so do we need to loop in social support systems here? And memory issues with taking the medications and risk for toxicity. And again, there's potential for different metabolism in this group of patients, polypharmacy. And goal is to build a system that's very integrative and collaborative using our allied professionals, the nurses, the social support systems, and the pharmacists on teams. And we can't do it just in silos. So and then just this slide, everything makes sense here, everything we talked about. Now health literacy is a problem. We're talking about wearables, we're talking about, oh, get an Apple Watch, yes, this is great. But how many can know how to interpret it? Or how many can afford? And what about the intersection of social determinants of health in these patients? And this is a very, I thought this, basically this infograph, pictograph really showed everything we talk about. So we need support of the caregivers. We need to break the barriers of practicing electrophysiology in silos. And we need to team up with heart failure gerontologists and our support system, including the social workers. And the research gaps and how do we close those? Basically, screening these patients and not excluding them from the trials. Because if we are seeing a larger growth in the population with increased burden, if we start, we don't include them in our trials, we'll still be doing this talk 15 years down the road. So I think very important to avoid under-prescribing oral anticoagulants. Yes, the bleeding risks are there, but then we need the help of occupational, physical therapists, collaborative care, and also getting help for the medications that they can't afford. Assistance from the pharmacologists, and hopefully lobbying to say, make these medications cheaper, please. And everything is, you know, I'm gonna, literally everything we talked about is here. And setting aside, this is something we'd like to know from the audience at the end of it, but I struggle with making time, listening to these patients, especially when they come without a family member. It's very hard, you know, we're talking about, oh, I'm gonna put a monitor on you, and we do this. So making more time, and simple things, but we need to make more timed value units when we take care of these patients. Now, last slide, last two slides are the ageism and the wearables. The wearables are coming at a pace we are unable to keep up. And we need external stakeholders, device designers when they're using, you know, when they design it, they need to take older population into account. And support of the family members, the researchers, and ease of use where we might need, you know, patient care navigators to help us. And device integration, ultimately keeping the end user, the end user is the patient, the older patient. And mitigating ageism and wearable technology, ensuring clear data policies, and having maybe, you know, preparing them, giving them more time to get used to the wearables, or the monitors, knowing why we are doing things, which means extra time from the clinician, the workforce, and we are really short on the workforce. So, but these are all, you know, good discussions, and hopefully we'll move the needle in the right direction for our patients. Thank you so much for your time. Thank you. Thank you, Dr. Tamarisa, excellent talk, lots of great information. Our final speaker is Dr. Laura Gravelin, and she'll discuss addressing disparities in cardiac electrophysiology care in women. Thank you. Hello, I'm Laura Gravelin, I'm a hospital-employed electrophysiologist practicing in Columbus, Ohio at the Mount Carmel Health System, and I want to thank our panel chairs for the opportunity to talk about a topic I'm fairly passionate about, addressing disparities in cardiac electrophysiology care for women. So the Lancet Women in Cardiovascular Disease Commission is trying to reduce the global burden of cardiovascular disease in women by 2030. We know that cardiovascular disease is the number one killer of women, and we know that when it comes to cardiovascular disease, women are understudied, their disease is underrecognized, underdiagnosed, undertreated, and women are underrepresented in clinical trials. Typically, the average cardiovascular clinical trial has about 25% of the patients enrolled as women. We know that women benefit from atrial fibrillation ablation, but they're less likely to be referred or receive that intervention when compared to their male counterparts. We know that women do better with CRT, even with less dyssynchrony, and they are less likely to be referred and receive that therapy when compared to their male. Counterparts. So at this session in 2019, Dr. Ann Curtis presented these data. Patients who met guideline criteria for ICDs and CRTDs in the setting of primary prevention, 16.7% of men received the device compared to 12.7% of women. I heard a lot of conversation around this. People, I think, were in a little bit of disbelief. I certainly don't practice that way. That doesn't happen in my health system. But in fact, other health systems reported very similar data. We looked at our own data from 2016 to 2017, and in that year, we found that 1,647 patients had echocardiograms with reduced ejection fraction. We actually were not very good at getting them their device or a visit with an EP. We only had 18% of patients who qualified for devices getting it. There's this large group of patients who come to our health system where they get their index diagnosis of heart failure with their low EF, and we never see them again, not in the hospital setting, not in the outpatient setting. Then there's this intermediate group where 614 patients are getting their follow-up, but they don't see an EP and they don't get a device. Well, a good portion of them, 354, actually have recovery of their ejection fraction, but there's still this 280 patients in this calendar year that qualified for a device and weren't getting it. So we looked at this by gender, and not surprisingly, men were more likely to get their device when compared to women. We controlled for QRS duration, atrial fibrillation, body surface area, EF at the index echo. We also looked at race. If you're a white patient, you are more likely than a black patient to get a device. These data are not new. You have heard this before, and the question is why is this happening? I think we've heard if we don't do something now, we're gonna be here 10, 15 years later. We all have a suspicion and inkling of why it might happen. I personally think if you grow up in America, you have unconscious bias. I think the time we spend with patients is getting shorter, and yet we have larger amounts of data to synthesize and make a plan. So I wondered, could we use AI to identify patients who qualify for their defibrillators but aren't receiving it? I did not get this project off the ground by myself. I'm a full-time clinical electrophysiologist in a hospital-employed position, but I was lucky enough to have a friend and mentor, Smita Dolan, while she was at Medtronic, who said, you seem really excited about this. Why don't you write a protocol, submit it to Medtronic for an ERP for a grant, and see what you can do? Now Medtronic had been working with Empiric. They had an artificial intelligence, it's a natural language processing AI. Basically looks at the data and electronic medical record, builds a patient profile, and then runs it through an algorithm. Is the EF low? Yes. Do they have a follow-up echo? No. Then it would get alerted. They were using that AI already in the structural heart space to identify undertreated patients who had low-flow, low-gradient AS. So put that all together, and my local health system was kind of lukewarm about it. So the reason I have that data from 2016 is because they made me prove that we needed to do this pilot study. Then my health system is part of the bigger Trinity Enterprise, and we were going live with Epic. And while there was physician support for the project, once I started to have to present it to vice presidents of finance and business administration, there wasn't a lot of embracing. So locally, my director of research operations and one of our IT team, Dreena Tennant, they were huge supporters. I have, I think, a guardian angel in the CMO at the enterprise level. He really, I think, tapped someone on one of these committees and said, just push it through. This sort of synced up with the release of ChatGPT in November 2022, so all this AI stuff was becoming mainstream. So I had a protocol and grant funding in September 2021. We went live March 2024. So it took a while, but my boss likes to say, EP means extra persistent. So we started collecting data, and I will tell you, we have not done statistical analysis because we started at the end of March. We're gonna collect all the data for the patients to the end of March, plus at least three months more. We wanna make sure we give those last patients in enrolling, if you will, an opportunity to get an echo so we can see where we're at. But we found we actually got better at putting in devices. So if you recall our retrospective data, 18% of patients got what they needed. 32% are getting it in this contemporary arena. We still have this 40% of patients that come in and are never seen again. In Columbus, the main health systems all have EPIC, so you can see who shows up at other health systems, if you will. And then we have this middle group again, this 473 patients. And I'm going to give you descriptive statistics. We have not run data analysis. So when we look at the total population, this 1,716 patients, 70% are men and 30% are women. And when we look at who needed an alert, meaning the AI recognized somebody as undertreated, 67% were women, sorry, 67% were men and 24% were women. So I'm not sure if we're necessarily gonna see a statistical significance. When we look at the race makeup, 69% were white, 21% were black. And when we look at who required alerts, 57% were white, 43% of people were black. And I started to think about these patients who just don't show up again. In Franklin County, we have zip codes for at-risk individuals. We know that they're living in food deserts or they don't have access to transportation or healthcare. And so we looked at who's represented in those zip codes. And for patients who are getting their devices, 6% of them are in at-risk zip codes and of the people who alerted, 10% are in at-risk zip codes. Now, when we look at this 473 plus 690, we're not getting alerts on everybody, right? That's what the natural language processing is supposed to be doing. It's looking and see, yes, they are in the chute for appropriate care, they have an echo, they've been scheduled to have an EP visit, they have an outside cardiologist, they follow at the VA. We also are excluding people who've missed three office visits in a row, although that's probably the population that needs some extra attention. What we did with the workflow is we decided purposely that everything would come through me. So there were 197 alerts. I wanted to adjudicate them as the AI is learning because I didn't want my colleagues, my physician colleagues, my APP colleagues to get alert fatigue or get faked out by something that maybe wasn't accurate. We also wanted to figure out how we could make the AI smarter, where we could make it look more closely. So not unique to this project, AI has a really hard time determining if patients are dead. So we created a flag on our side so that the AI could see that the patient was dead, and so we're not alerting on patients who have passed away. But that means I've really gotten to look into the medical records and see a little bit of what's going on. So we talked about facets in a sense of why there is disparity, and this is just sort of another part of that. And it's anecdotal, not data. But this is what gets documented in charts. Patient feels well and does not want ICD. So on my most generous days, I think, okay, this is under-documented. It was a great conversation. You know, just have to work on documentation. On the days when I feel most despair, I think, why is this patient not in my office? If I have a perhaps symptomatic patient who has moderate, severe AS, I'm sending them to Structural Heart. They're the experts on the procedure. They can talk most clearly to the patient about the outcomes and what to expect after. Here's one where I actually think it's pretty good documentation. I've discussed the need, primary prevention, sudden death, the patient's gonna think about it, talk to their family, call us back. So that happens in the office, but then this patient goes to checkout and gets a one-year office visit. There's no follow-up phone call from a nurse, no bringing them back with their family, no telemed follow-up. So the message is, I'm good for a year. And then this is sort of the most concerning. This is a patient, the physician is talking to the patient in terms of secondary prevention for coronary disease, but also risk for sudden cardiac death, and they basically say, functional capacity is good, can walk, we're gonna leave it at medications. There's absolutely zero discussion about sudden death and what sudden means, and that, I use the example of DeMar Hamlin on the football field. You can be in excellent physical condition and still have an issue. So I've been thinking about how to have conversations with colleagues and not alienate them, and I'm really not coming up with a lot of ideas, so if you have had these conversations and they've worked well, I would love to hear about it. So what's next for this? I graduated fellowship 13 years ago, and I think I knew more, or I thought I knew more then than I do now. There's a lot of discussion because women are underrepresented in clinical trials. Do they actually benefit from primary ICDs? And there's some sub-analysis that would suggest maybe not. Now we all have that, patients who did have cardiac arrest or device save them, but what did the data tell us? The data have to be powered to tell us to know for sure. Implementation science is a phrase that I really didn't know what it was. I kind of used the synonym workflow. In the next couple of months, we're hoping to take all the alerts away from me and start pushing them out to the cardiologists and the APPs. We think we have the AI in a place that it's more accurate and reasonable. We're also gonna continue to improve that natural language processing. My IT colleagues tell me that the big language models are coming and the natural language processing is gonna be even smarter, more accurate, and better at detecting who needs what. We're still collecting the data and doing the analysis. And so for actionable items to address this, this was a personal calling for me. I needed to do something other than just take care of patients, and I'm hoping that this AI is the beginning of an opportunity where we can more widely apply it and identify patients who are undertreated. I'll share just one quick anecdote, which I'm full of today, evidently. There was a patient who we could see had their index diagnosis, came in for two or three office visits, and then canceled three or four of them. So our scheduler called him and come to find out he's visually impaired and he has a seeing eye dog, and his insurance will pay for transportation for him to go to his office visits, but the transportation company switched, and they go to his home, and they don't allow animals in the vehicle. So we were able to work with the population health team, get him a car company that will allow his seeing eye dog, and now he's in our heart failure clinic. And that's a totally different facet of how all of this can happen. But I'm hopeful, and I hope you are too. Thank you. Thank you. Fantastic presentation. Thank you for all the presenters. Those were excellent. Provocative talks, really appreciate it. If any members of the audience have questions, please step to the microphone. I'm gonna start if that's okay. Dr. Tamarisa, great presentation on older populations, and mainly atrial fibrillation and other issues. My first question is how do you use frailty, and how do you use something like the frailty index to sort of guide your management, specifically with procedural rhythm control in older patients? To be honest, I know the frailty index should be incorporated, and that's there in AFib management. But I look at the BMI of the patient and how active, so I kind of ask them, how much are you able to walk in a day, and how long does it take for you to get your day-to-day ADLs done? That's number one, and then I also look at how big the size of a patient, the BMI, because for procedures, the thinner the vasculature, just like in women, complication rates are higher, so I do worry, independent of AFib, but devices too, they're very lean, and then, of course, take the third one, is their comorbidities, or coexisting medical conditions, how well is their diabetes controlled, how high is their creatinine, and then hypertension management. And the last thing I'll tell you is the food insecurity or the poverty, are they having enough nutrition, what kind of social support system do they have? I think they all play a role in that, in making a decision. Thank you. Can I just add to that? Annabelle Volgman from Rush University Medical Center in Chicago. We're very proud for all the things that we're doing for our west side of Chicago, because of the longevity gap in our city. Rush implemented a way for people to get oral anticoagulants at a much cheaper rate, so it's like $40 for three months, if you write a special code. So one way we can decrease healthcare disparities is by doing things like that on a big scale. So I'm asking people to think about doing something like that, because that is the way you can change that. Could you elaborate, and how do you make that, because I've been trying real hard to help, so could you give us? Yeah, no, we have, when you write a prescription, it's sent to our pharmacy, and it has to indicate, please use 340B pricing, and it's like the catchphrase that you have to use. And our university medical center negotiated with the pharmaceutical industry to give that pricing. I'll go with the next question, if there are none from the audience. This is for Dr. Gravlin. I know this era with AI is certainly sexy, and seems to be the way of the future. So you're still gathering data, but did you see any gender disparities in the prospective study, and if not, why do you think that was? Yeah, I think AI is both sexy and terrifying. I don't think we're getting, oh, sorry. I was saying that I think AI is both sexy and terrifying, but I think the indicators we have without doing statistical analysis that doesn't really show a gender difference, I think could be the Hawthorne effect. I am at a single site, I talk about women's disparity with defibrillators, atrial fibrillation, all of the time. I've talked about this AI project for two and a half years before we went live. I wonder even if that's why we went from 18 to 32% when we started our prospective study for people getting what they needed. I mean, at my institution, we didn't have a women's heart program for the first couple of years I was there, and I had to find a partner to champion it for us to get that started. The great Dr. Crispin. You spoke very intelligently about the AFib paradox and this idea, for example, underrepresented racial and ethnic groups clustering more classic risk factors associated with AFib, but having less AFib, and I think study after study has demonstrated that outside of the Heckberg study with the monitoring, but help our audience understand some of the theories that you think may be going on that may explain that. Yeah, so certainly genetics does play a big role. You know, certainly AFib is multifactorial, but it's been a lot of data showing that there's certainly a genetic predisposition for this. One of the interesting studies I've seen from actually from Framingham, so it's not a very diverse population, but they found though is that if you had a parent or a sibling who has atrial fibrillation, your risk of developing AFib was twice as likely even if you had the same risk factors of high blood pressure or diabetes. I didn't show that image just for time, but so I certainly think there's a genetic sort of component to it. But I also think that while, like you mentioned, most of the other studies didn't sort of corroborate what the Heckberg study showed, I don't think the gap is as wide, to be quite honest, and I do think that we are missing a lot of AFib diagnoses just because you're just not looking for it. I think if you seek, you will find in the world of AFib, even in terms of what we do for our procedures, looking at what are our outcomes afterwards, the longer you monitor people or the more intensely you monitor them. If you do a two-week monitor for something that happens a couple times per year, you may not pick up AFib, but if you put in a continuous monitor, then you may actually see some pick up more AFib. I think some of the data from pacemakers and ICDs suggest that maybe there is a difference, but also, who's getting the pacemakers and ICDs? We see that it's not really representative of the overall general population. And so I think we need to do better in terms of enrolling more diverse patients into these sort of epidemiological type of studies, into our clinical trials, to really sort of define what is the incidence prevalence of AFib in the population. But I do think genetics, there are some genetic component things as well. And I think one could argue, if you don't have access to the health system, you're not getting diagnosed with anything. Correct, correct. And so access to care is the first step. And so if you're not seeing a doctor, if you're not telling them about your symptoms, like I said, most of these symptoms are pretty nonspecific sort of symptoms. It's not like, oh, I have chest pain, my arm is numb, or something like that. And so when you come into your doctor with these sort of symptoms, and you say you already have a diagnosis of heart failure or HFPEF, it's like, oh, it's just probably a result of your heart failure causing this. And you may not notice that HF preparation may be sort of contributing to your symptoms as well. And I do make a big point of just, in terms of the amounts of monitoring you do, we actually had a meeting with our AP group about, should we just get rid of 24, 48 holters? You shouldn't even be able to prescribe something like that, because you're not really gonna get, the utility of that is pretty low, and it's usually kind of the first thing that people order. But the other thing, too, is also access to care. So, in Baltimore, a lot of patients who are in underserved areas, they have sort of like a Medicaid equivalent, and you actually can't order a 14-day holter monitor. You actually have to order a 24, 48 monitor for these patients, because insurance won't pay for it. And so that's just another layer of just complexity adding to this problem. Excellent. Dr. Gravelin, I would wonder if you could help me and the audience think about, we have under-enrollment of women in a lot of clinical trials, certainly in cardiovascular disease, certainly in EP. In your mind, what are some strategies that may help improve that? Well, there was a summit yesterday with Dr. Curtis and Dr. Russo leading it, talking about getting more women PIs for clinical trials. I think that makes a difference. I will say that the alleviate heart failure trial is looking at software on the loop recorder to detect heart failure. They enrolled patients who had lower EFs, but also diastolic dysfunction, and that's a study that's gonna have 40-something percent women. It took me a little bit to form this question, but I'm a genetic counselor, and my niche is diversity equity within the genetic counseling profession. But I starkly remember when I first started learning, which was very early in my career, that disparities exist in genetic testing. I was so distraught, I thought that I would change professions and become a community health worker trying to get access, improving access, right? The number one, how do you get people in the door? My question for the panelists who are clinicians is how do you balance that clinical workload that you have, seeing your patients regardless of what got them to you, the people showing up who you're responsible for, with the knowledge that you're in this inequitable system and you should be seeing a pretty different array of people. What do you do in your day-to-day to give you peace of mind in that tension? That's a million-dollar question, and Annabelle, Dr. Borgman had a very, I'm gonna talk to her about solution, but I can tell you, I think maybe this anecdote, I'll take 30 seconds, but just an anecdote might not answer your question in full because I genuinely don't have an answer, but recently I had a patient who has zero health insurance. She just moved to Texas, and she works two jobs, and she's PASA-dependent, and she tried to get insurance, but they said you have a pre-existing condition and you can't get it. Her battery is pretty much ERI, end of, you know. So just last week, I called our administrator. They didn't pitch in, so I went to their office, and they said, no, we can't help. Then I said, I threatened, I said, I'm gonna go to another healthcare system if you don't do it, and they were like, no, it's not that easy. I said, no, you make it easy because she's coming to the ER. I'm gonna give my time for free. I called our anesthesia colleague. I said, would you be okay just to sedate and give your time for free, and he said, absolutely, and I said, I'm gonna buy some Band-Aids from outside and get some, you know, whatever, and maybe people will donate some IV lines. What do you need? Finally, I got approval just when I was leaving, saying, no, no, you can do everything for free. So my answer is, if you have a patient, please be the patient's advocate. Keep pushing, keep pushing. We just need help. Patients need help. I know that doesn't answer at all, but. Yeah, I think personally, it's pretty depressing, right, to think about inequities in care. It's frankly embarrassing to be in a country like this and have this exist, but that doesn't mean we shouldn't fight and try to move things forward, and I think, unfortunately, we don't have enough people in this space to do this type of research, to see these types of patients in marginalized communities. So individuals like myself and those on the panel, you know, I'm just trying to pay it forward and train the next generation of people to take on this work. So it's a humbling process every day, taking care of patients in general, specifically marginalized patients, but that's not a reason to ever give up. I would certainly add, I think, you know, personally, I think it's, I think you should just always do what's right for your patient, right, and so somebody has a fib, you know, they should be on a blood thinner. You know, I think these are certain things that are just sort of standard of care things, and I think, you know, lack of resources or, you know, access to, you know, insurance and things like that shouldn't be sort of the barrier for you to say, okay, this person needs X, Y, or Z. Part of the issue is that sometimes patients come to you where some of these things are just not even discussed with them, which is sort of the disheartening thing. You know, I think of a guy I actually just saw a couple weeks ago who came all the way from, I think, I forget, from somewhere in Virginia, he came all the way to Baltimore, because he saw, he was looking for a black sort of electrophysiologist, because his EF was 30%, and it's been that way for a couple years. He's had a prior heart attack, and nobody ever talked to him about a defibrillator, and I think his buddy had a defibrillator, and said, why don't you have one? And so he came to find a doctor to kind of help find, like, why he doesn't have a defibrillator. So, but, you know, but if he's just sort of a person as an individual patient, you say, hey, you're on appropriate medication, so you have low EF, at least have the conversation to have a defibrillator. So I think for, you know, from that personal level, just making sure that you're just doing everything that you can to what's right clinically for the patient themselves. But I do think that's probably an area where, you know, big data and sort of these AI things may be helpful to kind of give a report card to, you know, programs and hospital systems. Kind of like the data you showed, where you have all these patients who had low ES, but none of them were referred to an EP for considering for an ICD. So what if they actually had that sort of data, like we do now, I guess, for things like high blood pressure and diabetes, can I say, like, how good of a job are you doing in terms of that kind of care? And I think that would be kind of an opportunity, at least, to address, you know, for individual physicians, like, hey, oh, why is it I didn't put this person on a blood thinner? You know, is there a reason for that? And I do think that's where kind of AI and big data may be helpful in that sort of sense. I agree. I certainly would like to thank the panelists. Excellent job, and I would like to thank the audience for spending your hour with us. Thank you.

cardiac electrophysiology

racial disparities

atrial fibrillation

anticoagulants

older adults

clinical trials

AI technology

unconscious bias

healthcare advocacy

equitable care