Well, I'd like to thank ACC for the invitation to talk, especially to kind of continue on with this session. I'm going to be talking about some cases, and it's going to be very interactive. I'm going to ask leave of my co-moderators to answer some questions for some discussion. And we'll be introducing some cases. I would really love it if you guys would participate in actually answering some of these questions, because they do talk about a lot of the patients that we end up seeing in our practice, and to actually think about how we approach these patients, particularly when the science is clear, but everything else that surrounds it is not exactly as clear. As we all know, life happens, and this particular session or this particular case, these particular cases are going to be talking about the social determinants of health and how they affect treatment of atrial fibrillation. So, like we said, participating in the audience response system, if you'll do that. You can also go into the app, and if you go into the session, there's a special area that you can actually hit on to get the questions. All right, so case number one, we have Mr. Jackson. He's a 68-year-old African-American man. He came into clinic and he was complaining of palpitations and fatigue. He had mild dyspnea, and this worsened over the past three months prior to him coming in. In talking to him, there are a few things that are important. First off, he first felt palpitations about eight months prior, and was diagnosed with atrial fibrillation four months ago. So there was a four-month period where nobody really knew exactly what was going on, mainly because nothing was caught, he had complaints, but he also couldn't reliably follow up with his private care physician because of work. Now, four months ago, he was placed on Warfarin, but, and he wasn't able to be placed on a DOAC because of cost constraints. In spite of that, unfortunately, he hasn't been able to go to the Coumadin Clinic because of some work restraints. He's a truck driver, he has to drive around, and he hasn't been able to make his appointments, and as a result, his INR sometimes is sub-therapeutic. His past medical history is significant for COPD, hypertension, diabetes, and a past TIA, but he's doing okay now. He's married, he lives in rural Mississippi, works as a truck driver, he does have Medicare, but he doesn't have supplemental insurance. He has a high school education, annual income of $50,000. At first, the tests were done. Basically, everything was okay. A transthoracic echo just showed that he had moderate left atrial enlargement, but his ejection fraction is normal, and he has no valvular abnormalities. So thinking about this patient in his entirety, and given his rural location, limited financial resources, and the outcome of his TIA or stroke, which approach would be the most likely to improve his management and prevent further complications? A, would be referral to a catheter ablation at an urban center with a charity care program. B, transition to a DOAC through pharmaceutical assistance programs and implement home-based telemonitoring. C, continue Warfarin, but establish a community health worker program to assist with transportation for his INR monitoring. D, implement primary care-based integrated care model with telehealth support from electrophysiology. And E, prioritize involvement in a clinical trial that provides comprehensive care and monitoring. ♪♪♪ ♪♪♪ Okay, so it looks like folks were kind of in between A and B, with D coming a distant third. So I'm going to go back to the question, and I'm going to ask some of my colleagues, what would you recommend? What would I do? Yes. I think if there is a combination of A and B, because DOAC is definitely the right choice for him. He's a truck driver, can't even get to appointments. I mean, you know, there's a lot of constraints for him. And so getting the DOAC is important with some case of, you know, home-based monitoring, so to help him. And I, you know, would you jump in and do an ablation without even managing the stroke and, you know, the other risk factors for him? I would take time, discuss, and say, we already took four months to start anticoagulation, and so having a seat with the patient and starting the DOAC, opening a dialogue towards, you know, ablation. Because, again, using the latest guidelines, independent of them, too. If we prescribed another medication, antiarrhythmic, again, cost and difficulty, follow-ups, and these. And we know, you know, the effectiveness of antiarrhythmic medications is less than 40%, 20%. So I would definitely, you know, go with A, but B is my starting point to end up there. I mean, the first pillar of management of atrial fibrillation is anticoagulation, especially if there's an intention to proceed with an ablation. So, but it has to be a realistic plan. And at least where I practice, DOACs are very difficult to, in terms of affordability. So there is specific hospitals in my community where there's specific programs that can offer DOACs, but it would be for a short period of time. So Warfarin used to work in the past. There's no reason why, under certain circumstances, if this is the only realistic plan, we should not start it. But, you know, it would be a bridge to do something with more definitive. So, you know, we think after ablation is, it is something that could decrease, not only his symptoms, but also his thrombobolic problems for the future risk. So with the mind that, you know, he would have been normally kind of for a cath ablation, but he needs a stable management, a stable anticoagulation regimen. So first would be get him to, I think, to Warfarin, make sure he's okay with that, that he follows up, and also with the intention to refer him to a center where you have an ablation. So I brought up this particular case because even though some of the locations, and of course the name was changed, this is representative of a few of my patients. And, you know, in treating patients who, apart from discussing the medical part, right, which is this man has, you know, a lot of comorbidities. He has a high CHAZ-VASc score. We know he needs to be on anticoagulation, but he comes to you with very real problems. He has some financial constraints. He is on Medicare, and everybody thinks that Medicare is, you know, the end all, be all, like, thank goodness you're on Medicare, but people don't realize that if you don't have either a Medicare Advantage plan, or if you don't have a supplement, especially for somebody who is low income, there's still considerable cost, 20% of all interventions, like if you're hospitalized, for instance, you have to pay 20% of that, or certain medications you're not able to get because of contracts that were done, you know, by people who are not as, but basically, even those coupons that you're able to give to patients who have commercial insurance, you can't give those to those, you cannot give them to those who have Medicare because it doesn't really help. They cannot get those $10 copays. And so this is a very real problem that you have to consider when you see a patient who comes in with atrial fibrillation in the hospital, and you're making recommendations. And the reason why this is important is, you know, basically because of what happened to Mr. Jackson following. So he was referred to EP evaluation. The closest EP was about 120 miles away. His appointment was nine months after his initial presentation to the clinic. And four months after this primary visit, he experienced a stroke, another stroke, and this time resulting in left-sided weakness and speech difficulties. And it's well known and documented that strokes that are related to atrial fibrillation are actually higher in mortality, higher in morbidity. So this is not surprising, and this is the reason why we stress that if you have a high risk for stroke based off of your CHADS-VASc score or any other risk score that you use, then you should be on anticoagulation as soon as possible. And so now post-stroke, he requires assistance while living at home. This, of course, places significant financial strain as well as, you know, emotional strain on his family. So this is unfortunately not a good result for this patient. So moving on, case number two. We have Ms. Rodriguez. She's a 56-year-old woman of Peruvian descent. She came to the emergency room with severe palpitations and dizziness. She was previously diagnosed with paroxysmal atrial fibrillation about 18 months prior. She's very anxious because she has two jobs, and actually she just lost one of them as a result of her continuously coming to the emergency room for treatment of her symptomatic episodes. She's afraid that she's going to lose her second job, which she has as a cleaner. She has not followed up with a primary care physician because she does not have insurance, and she is not on oral anticoagulation at this time. She was given a referral for paperwork at her last visit. She doesn't really speak English, and that was given in English so she didn't understand what was going on. She does have hypertension and diabetes, and she is a woman, so she does have a CHAZ-VASc score of three, and she lives with her daughter. She's uninsured. She doesn't speak English fluently, as I mentioned, and a transthoracic echo that was recently done shows severe left ventricular dysfunction with an ejection fraction of 20 to 25%, moderate mitral regurgitation, and this is significantly changed from a prior echo that was done at a prior visit about four months ago. So in this patient, she continues to have symptomatic atrial fibrillation and remains at high stroke risk without anticoagulation. So which approach do you think best addresses her unique barriers to care? Enrollment in a county hospital-based comprehensive AF clinic with evening hours in Spanish language services, prioritization for same-day anticoagulation clinic access with medication assistance program support, referral to a community health center with integrated behavioral health support to address anxiety about her condition, mobile health unit follow-up with language concordant providers and flexible scheduling, or patient navigation program with culturally tailored AF education and assistance accessing safety net programs. So we have also, and this is one of the questions that's kind of, it's a mixed bag. I don't know if anybody has anything to discuss or want to point out. I think this is a patient who is as sick as it can get. And this is the patient that, you know, us as cardiologists and particularly electrophysiologists can really make a difference in her life expectancy. So this is where we need to be aggressive. This is our stem in terms of, we're talking about electrophysiologists. So what did you want to say? I think they're all important interventions. I'm sure they all would be fantastic, you know, better than nothing for this patient, obviously. But when we talk about, you know, why women present late, why women present acutely with stroke, why women present acutely with heart failure exacerbation, you know, reading this clinical picture is exactly why, because a lot of us aren't aware, don't perhaps don't have access to programs like these to be able to offer. And I can tell you that in patients who have, who do not have insurance, it is, you know, you either, you have two groups of two attitudes in patients who don't have insurance or two main attitudes. One of them is, you know, I don't have any money, so you can't take blood from a stone. So, you know, do everything and they'll send me a bill and whatever it is, what it is, right? But then you also have a group of patients who will not show up in the hospital. They're very upset that they have to go to the emergency room. They try to pay their bills as much as possible. And actually that increases their stress, which basically causes them to go into more atrial fibrillation because they have more anxiety as a result of their condition. And so by not intervening or not doing something definitive, we can actually increase the worst outcomes that can happen as a result. So it is very important that in spite of, you know, the presence of insurance or financial, the ability for the patient to financially be able to take care of their disease, yes, that is important, but then also I think that we should take it upon ourselves to treat the patient first before we start navigating everything else that goes around the disease process. And so in this patient who comes into the emergency room, you know, the first thing that was done was to decide, okay, first of all, we need to get her out of atrial fibrillation because she is in atrial fibrillation with RVR. And so they did a transesophageal echocardiogram and a direct current cardioversion during her admission. And during the same admission, patient education was performed. They made sure to give her, with a Spanish interpreter, instructions on what to do, give her resources on where to go, particularly taking into account her financial situation. Coincidentally, the EP physician that was on call that day happened to also have a clinic in the safety net hospital and was able to get her a quick appointment for follow-up. And she was able to get an ablation after getting cardioverted. And now she, a few months later, she's post-ablation, her ejection fraction was improved. She was started on guideline-directed medical therapy and she's able to continue her regular activity without difficulty and she remains on a DOAC. So these two cases showed what can happen where there's appropriate intervention and what can unfortunately happen when there isn't appropriate intervention and when these other social determinants of health are not taken into account when taking care of our patients. We talk about social determinants of health being those factors that affect your health welfare outside of medicine. And that includes the factors that affect where you work, where you live, and financial constraints, language barriers, educational barriers. Those things do affect healthcare and the delivery of healthcare. And we should definitely put that into account when we're taking care of these vulnerable patients. And with that, I'd like to say thank you. Thank you.

social determinants

atrial fibrillation

healthcare barriers

treatment outcomes

equitable care