Scaling Health Equity in Heart Failure, With Anita Radhakrishnan, MD

A pilot initiative targeting heart failure (HF) and hypertensive urgency (HU) patients in Pittsburgh’s North Side showed promising results in reducing hospitalizations and improving cardiovascular health metrics in one of the city’s most medically underserved areas.

The North Side Heart to Heart Project, launched at a major hospital serving the area, provides patients with free Heart Care Kits—including blood pressure cuffs, scales, and fitness trackers—along with regular monitoring from a cardiac nurse. Patients received weekly calls to report vitals and symptoms, with real-time intervention if abnormalities were detected.

In a new interview surrounding the American College of Cardiology (ACC) 2025 Annual Scientific Sessions, Anita Radhakrishnan, MD, a cardiologist at the Alleghany Health Network (AHN) Cardiovascular Institute, told HCPLive the program was born from a long-standing concern, as patients who resided in that city neighborhood were more often hospitalized than at an outpatient center for regular care maintenance.

“Knowing that our social vulnerability index in that neighborhood is much higher than other areas, that’s why we try to promote healthy equity in the North Side,” Radhakrishnan told HCPLive. “We found a significant number of hospitalizations over the last few years, specifically for these diagnoses, so we provided these kits and a nurse navigator who is a direct contact to our patients. We are seeing positive responses in how they view their health in terms of reductions in hospitalizations, and try to meet some of these biomarkers and risk calculations.”

Preliminary outcomes were encouraging, showing reductions in emergency room visits and improvements in New York Heart Association (NYHA) heart failure classification class, atherosclerotic cardiovascular disease (ASCVD) 10-year risk scores, and blood pressure levels. Patient-reported wellness also improved along with key lab values like pro-B-type natriuretic peptide (proBNP) and low-density lipoprotein cholesterol (LDL-C).

Radhakrishnan noted that sustainability remains a challenge. Early recruitment efforts included all eligible patients, some of whom lacked housing or struggled with substance use, leading to attrition. Midway through, the team adjusted enrollment criteria to prioritize patients more likely to engage with follow-up care.

Staffing also proved a limiting factor, with funding only allowing for a single nurse navigator for nearly 500 patients. Despite these challenges, Radhakrishnan suggested the initiative offers a scalable blueprint for addressing health disparities. With the full dataset expected to be available by late 2025, similar programs could be replicated nationwide to bridge gaps in cardiac care.

“It’s about making sure we target the right population, looking at vulnerable zip codes with increased heart failure admissions. There are a lot of electronic health record (EHR) indexes that allow us to identify patients that fall in that category if we utilize them the right way,” Radhakrishnan told HCPLive. “If we utilize it the right way, and you have a champion to run with it, it’s a very scalable program. It’s really something that could easily be replicated in any part of the country.”

Radhakrishnan reports no relevant disclosures.

References

Alnaimat S, Maharjan S, Jafry A, et al. The Northside Heart to Heart Project: A Diversity, Equity, and Inclusivity Initiative. Presented at: American College of Cardiology (ACC.25) Annual Scientific Session. March 29 – 31, 2025. Chicago, Il.