Misread Clinical Signals Perpetuate Disparities in Heart Failure Care

Breakthroughs in pharmacology and minimally invasive devices have reshaped the landscape of heart failure care, with dozens of targeted therapies achieving disease stabilization and improved survival in this vulnerable population. But one look through the dual lens of heart failure care is all it takes to understand that those benefits do not reach all patients in equal measure, according to Melvin Echols, MD, associate professor at the Morehouse School of Medicine in Atlanta, Georgia and Chief Diversity, Equity, and Inclusion Officer at the American College of Cardiology. 

“Heart failure can reach anybody, anywhere, at any time, and we have to understand that there are a lot of things that occur when a patient develops heart failure,” Echols said during a session at the 2026 Annual Meeting of the American Association of Heart Failure Nurses. “[As clinicians], when we see a patient in the intensive care unit who may have had heart failure for 10 years, we [think about] these algorithms or guideline-directed medical therapies that we are supposed to [prescribe]. But what happens when a person goes in for an elective procedure and ends up on extracorporeal membrane oxygenation (ECMO), in the hospital for 6 months, because of complications? How do you navigate this person’s history from the time they are [in the hospital] all the way to the time when they are ready to leave - if they are able to leave the hospital?” 

Treating the patient across the heart failure continuum means considering the patient’s journey not just during hospitalization but also in the immediate period after discharge. Home care, including the management of medications and appointments, can be overwhelming for recently discharged patients, many of whom continue to be vulnerable during their adjustment to life after hospitalization. Echols noted that patients are at the highest risk for decompensation that requires readmission in the days and weeks immediately following their discharge from the hospital. While inpatient care is focused on stabilization, it is the outpatient transition that has the greatest impact on long-term survival. The lack of social and psychological support during this transition period can lead to depression and non-adherence to medication regimens. 

Moreover, Echols stressed, inequity in heart failure care, which is deeply rooted in social determinants of health, can further complicate recovery for vulnerable patients. “The social drivers of health are not just the things that we list in textbooks,” Echols said. “They are all the things that are involved in that patient’s [life], that affect how they are going to be able to take care of themselves moving forward.” 

Multidisciplinary transitions to outpatient care, often led by nurses, play a crucial role in decreasing readmissions for heart failure and in providing patients with the much-needed support. In many clinical settings, the timeline of transitional care includes a transition-of-care phone call within 48 hours to check symptoms and reinforce treatment recommendations, followed by a face-to-face visit with an advanced practice provider within one week of discharge. Nevertheless, these checkpoints may represent missed opportunities if providers fail to understand the social and psychological factors that may have an impact on patients’ recovery. “Every single sequence that the patient will [go through], the check-in period, the doctor [visit], the check-out period, all those are opportunities to engage the patient and make sure that we understand exactly where they are in terms of their mindset,” Echols explained. “Every single patient is important and we should be trying to make sure that we customize their management.” 

An optimized transitional care plan should go beyond the optimization of guideline-directed medical therapies and include strategies for high-risk mitigation, such as psychosocial support evaluation, management of comorbidities, and assessment of health literacy levels. “Labels are helpful to a certain extent,” Echols added. “But if you are going to label somebody high-risk, that needs to come with some sort of a plan. It’s really interesting to see the [use of] artificial intelligence and all the predictive models, the data telling us who is high risk in the hospitals, but, unfortunately, we don’t have actionable components. They are labels just telling us that people are high risk.”

In the era of multiple targeted therapies that have the potential to prevent heart failure, disparities driven by biological assumptions continue to have a negative impact on healthcare for certain underserved populations. Research focusing on disparities in cardiovascular care has shown that the gap in cardiovascular deaths between white and non-white Americans has continued to widen over the past two decades. National age-standardized heart failure hospitalization rates remain significantly higher for black individuals compared with white cohorts, with virtually no improvement between 2002 and 2013 despite advancements in medical science and technology [Morris AA et al. J Card Fail 2022; 28:1169-93].
 
“We have had all of this history, all of this time, all of these advances, and we still have these huge gaps in care,” Echols remarked. “So, what is the tipoff? Is it medication cost, is it missed visits, is it rising creatinine? What do we need to figure out to lessen this gap? A lot of it must come from misreading the signals. Importantly, for stage A and stage B heart failure, which are not technically classified as symptomatic heart failure, there are a lot of people in those [groups] that are right on the cusp of heart failure.” 

More attention should be paid to the other side of the heart failure spectrum, as interventions in the early stages could prevent progression of disease in many cases, Echols stressed. “When we talk about misreading the signals, it is very important to understand that words matter,” he added. “Where the system may see non-compliance because someone is not following a prescriptive instruction, it could be simply that they cannot afford it. I think we are penalizing poverty to some extent, framing it as a medical risk.” 

Interpreting clinical signals correctly is key to early intervention and risk mitigation. Given the limited interaction with patients in the outpatient setting, providers may miss physiological and psychological signals, while systems often miss social vulnerabilities. Nursing staff can play an important role in deciphering some of the reasons behind non-compliance, including unaffordability, lack of logistics, prior clinical harm, or limited health literacy. Moreover, community outreach may help turn the tide in healthcare disparity. “Trying to bring everything to the Mecca of a hospital and do everything at the hospital is not going to work anymore,” Echols said. “We need to take a step back and say, how do we reach people where they are and how do we get them the resources that they need? This could mean not just in clinics, but also in local communities, in local pharmacies. There are opportunities to reach people more than ever through these decentralized mechanisms. Those things have to be done in a manner where the community will be able to trust you. You can’t plop into a community and think that you are going to change the world in two days. There is a lot that we can do from the relationship aspect, but it does take time.”

Fixing the pipeline of heart failure care requires addressing multiple structural problems, from the interpersonal level to policy and health system levels. Increasing research inclusivity may help eliminate the evidence blind spot by ensuring that clinical trial interventions and outcomes also apply to underserved populations. 

“Overall, we are still in a challenging time of disparity,” Echols concluded. “What we should try to do is understand that, as clinicians, we are in this to help everyone and to make sure that everyone gets the care that they need. We should never underestimate the value of talking to patients and building relationships with patients. Patients rely on [providers] for everything.” The speaker emphasized that nurses, who serve as primary caregivers, advocates, and educators, play a key role in shaping health outcomes, as well as patient safety and satisfaction.