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Racial and Ethnic Disparities in Incidence and Prognosis of Perioperative Stroke Among Pediatric Cardiac Transplant
Laura L Lehman1,2,3, Elizabeth Mostofsky3, Soziema Salia3,4
1Department of Neurology Boston Children's Hospital Boston MA.
Insights
Black children have lower odds of perioperative stroke after heart transplants but face significantly higher mortality rates beyond six months. Addressing care disparities is crucial for improving outcomes in this population.
Area of Science:
- Pediatric cardiology
- Transplant surgery
- Health disparities research
Background:
- Black children generally experience higher stroke incidence and post-stroke mortality compared to White children.
- Black children undergoing cardiac transplantation exhibit increased mortality rates starting six months post-procedure.
- Existing data does not clarify racial and ethnic disparities in perioperative stroke incidence and mortality among pediatric cardiac transplant recipients.
Purpose of the Study:
- To investigate racial and ethnic disparities in the incidence of perioperative stroke among pediatric cardiac transplant recipients.
- To examine racial and ethnic differences in all-cause mortality following perioperative stroke in this patient group.
Main Methods:
- Analysis of the Scientific Registry of Transplant Recipients database for pediatric first heart transplants (January 1994 - September 2019).
- Multivariable logistic regression used to assess the association between race/ethnicity and perioperative stroke.
- Multivariable piecewise Cox regression employed to evaluate the association between race/ethnicity and mortality among perioperative stroke survivors.
Main Results:
- Out of 8,224 pediatric cardiac transplants, 255 (3%) experienced perioperative stroke.
- Black children demonstrated 32% lower odds of perioperative stroke compared to White children (aOR, 0.68).
- Post-stroke, mortality rates were similar for Black and White children within the first six months (aHR, 0.99), but Black children had over a threefold higher mortality rate beyond six months (aHR, 3.36).
Conclusions:
- Pediatric cardiac transplant recipients who are Black have a lower incidence of perioperative stroke than White recipients.
- While initial mortality is comparable, Black children who survive a perioperative stroke face substantially higher long-term mortality.
- Urgent identification and intervention for potential care differences are necessary to mitigate these racial disparities.
Abstract:
Background In the general population, Black children have a higher incidence of stroke and all-cause mortality after stroke than White children. Beginning 6 months following cardiac transplantation, Black children have higher mortality than White children. However, whether there are racial and ethnic disparities in incidence and all-cause mortality following perioperative stroke among pediatric cardiac transplant recipients is unknown. Methods and Results Using the Scientific Registry of Transplant Recipients, we studied children who underwent their first heart transplant in the United States between January 1994 and September 2019. Using multivariable logistic regression, we assessed the association between race and ethnicity and perioperative stroke. We used multivariable piecewise Cox regression to examine the association between race and ethnicity and mortality among survivors of perioperative stroke. Among 8224 children who had a first cardiac transplant, 255 (3%) had a perioperative stroke. Black children had 32% lower odds of perioperative stroke compared with White children (adjusted odds ratio, 0.68 [95% CI, 0.46-0.996]). Following perioperative stroke, mortality rates were similar for Black and White children in the first 6 months (adjusted hazard ratio [HR], 0.99 [95% CI, 0.44-2.26]). However, Black children had a higher mortality rate than White children beyond 6 months (adjusted HR, 3.36 [95% CI, 1.22-9.22]). Conclusions Among pediatric cardiac transplant recipients, Black children have a lower incidence of perioperative stroke than White children. Among survivors of perioperative stroke, mortality is initially similar by race and ethnicity, but beyond 6 months, Black children have over a 3-fold higher mortality rate than White children. Identifying and intervening on potential differences in care is essential to addressing these disparities.
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