Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators

Racial/ethnic differences persist in treatment choice and outcomes in isolated intervention for coronary artery disease

OBJECTIVE

Studies have noted racial/ethnic disparities in coronary artery disease intervention strategies. We investigated trends and outcomes of coronary artery disease treatment choice (coronary artery bypass grafting or percutaneous coronary intervention) stratified by race/ethnicity.

METHODS

We queried the National Inpatient Sample for patients who underwent isolated coronary artery bypass grafting or percutaneous coronary intervention (2002-2017). Outcomes were stratified by race/ethnicity (White, African American, Hispanic, Asian). Multivariable logistic regression evaluated associations between race/ethnicity and receiving coronary artery bypass grafting versus percutaneous coronary intervention, in-hospital mortality, and costs.

RESULTS

Over the 15-year period, 2,426,917 isolated coronary artery bypass grafting surgeries and 7,184,515 percutaneous coronary interventions were performed. Compared with White patients, African American patients were younger (62 [interquartile range, 53-70] vs 66 [interquartile range, 57-75] years), were more likely to have Medicaid insurance (12.2% vs 4.4%), and had more comorbidities (Charlson-Deyo index, 1.9 ± 1.6 vs 1.7 ± 1.6) (all P < .01). After adjustment for patient comorbidities, presence of acute myocardial infarction, insurance status, and geography, African Americans were the least likely of all racial/ethnic groups to undergo coronary artery bypass grafting (odds ratio, 0.76; P < .01), a consistent trend throughout the study. African American patients had higher risk-adjusted mortality after coronary artery bypass grafting (odds ratio, 1.09; P < .01). Race/ethnicity was not associated with increased mortality after percutaneous coronary intervention. African American patients had higher hospitalization costs for coronary artery bypass grafting (+$5816; P < .01) and percutaneous coronary intervention (+$856; P < .01) after controlling for confounders.

CONCLUSIONS

In this contemporary national analysis, risk-adjusted frequency of coronary artery bypass grafting versus percutaneous coronary intervention for coronary artery disease differed by race/ethnicity. African American patients had lower odds of undergoing coronary artery bypass grafting and worse outcomes. Reasons for these differences merit further investigation to identify opportunities to reduce potential disparities.

Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities

IMPORTANCE

Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities.

OBJECTIVE

To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach.

EXPOSURE

Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization.

MAIN OUTCOMES AND MEASURES

Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality.

RESULTS

This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization.

CONCLUSIONS AND RELEVANCE

Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.

Cardiovascular Disease in African Americans: Innovative Community Engagement for Research Recruitment and Impact

Historical events and the illumination of unequal treatment of cardiovascular and other diseases among African Americans and their white counterparts have suppressed African Americans' participation in research. Approaches that bring scientific professionals into actual partnership with affected communities show promise for overcoming this reluctance. Two examples are the Jackson Heart Study (JHS) and the emerging Moyo Health Network (MOYO). JHS uses layers of community engagement, including a pioneering effort to develop future health scientists and practitioners, the JHS Undergraduate Training and Education Center (UTEC). JHS-UTEC focuses on preparing young adults and teenagers (mostly African Americans) for rigorous higher-level learning and careers in health research and practice. MOYO is a mobile platform for health research to examine factors contributing to the development of disparities in the young while creating channels to disseminate interventions. Community trust in MOYO is substantially enhanced through its education and training program, which offers engaging ideation events along with app development and coding training opportunities to young people. Participants impart their cultural insights while using newly acquired technology skills to help with the community-focused design and launch of the network. The JHS and MOYO provide models for addressing cardiovascular health disparities by fostering community partnerships.

Racial and sex disparities in resource utilization and outcomes of multi-vessel percutaneous coronary interventions (a 5-year nationwide evaluation in the United States)

Background

There is a paucity of data regarding the racial and sex disparities in the outcomes of multi-vessel percutaneous coronary interventions (MVPCI).

Methods

The National Inpatient Sample (NIS) was examined for the years 2010 to 2014 to incorporate adult MVPCI-related hospitalizations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. We excluded patients with the missing race or gender data from the final scrutiny. Discharge weights were used to obtain the national estimations. The principal outcomes were MVPCI-related racial and gender disparities in terms of the in-hospital mortality and complications, and diagnostic and therapeutic healthcare resource utilization. Secondary outcomes were the length of hospital stay (LOS) and hospitalization charges. We used the Chi-square test and t-test/ANOVA test to equate dichotomous and continuous variables respectively. A two-tailed P of <0.05 was considered clinically significant.

Results

An estimated 769,502 MVPCI-related hospitalizations were recorded from 2010 to 2014 after excluding patients with the missing data (70,954; 8.4%). Black male and female were the youngest (62±13, 64±14 years). The highest non-elective admissions (M: 72.8%, F: 71.2%) were reported among Hispanics. Non-whites showed a higher proportion of comorbidities with lower resource utilization than whites. Hispanic males (OR 1.23) showed the highest odds of the in-hospital mortality whereas among females, Asians (OR 1.51), blacks (OR 1.35), followed by Hispanics (OR 1.22) revealed higher odds of in-hospital mortality. Odds of cardiac complications were highest amongst Asians (M: OR 1.19, F: OR 1.40). Black (6±8 days) and Hispanic (7±9 days) showed the highest length of stay among males and females respectively. Total hospitalization charges were highest among Asians. There was a greater increase in the all-cause mortality in non-whites from 2010 to 2014.

Conclusions

This study determines the existence of racial disparities in resource utilization and outcomes in MVPCI. There is an instant need for interventions designed to govern these healthcare discrepancies.

Racial and Ethnic Disparities in Health and Health Care

A health disparity is defined as an increased burden of an adverse health outcome or health determinant within a specific subset of the population. There are well-documented racial and ethnic disparities throughout health care at the patient, provider, and health care system levels. As the minority populations within the United States grow to record numbers, it is increasingly important to invest in efforts to characterize, understand, and end racial and ethnic disparities in health care. Inequities in health outcomes and care pose real threats to the entire nation's well-being. Eliminating health disparities is fundamental to the well-being, productivity, and viability of the entire nation.

Do gender and race/ethnicity influence acute myocardial infarction quality of care in a hospital with a large Hispanic patient and provider representation?

Background. Disparities in acute myocardial infarction (AMI) care for women and minorities have been extensively reported in United States but with limited information on Hispanics. Methods. Medical records of 287 (62%) Hispanic and 176 (38%) non-Hispanic white (NHW) patients and 245 women (53%) admitted with suspected AMI to a southern California nonprofit community hospital with a large Hispanic patient and provider representation were reviewed. Baseline characteristics, outcomes (mortality, CATH, PCI, CABG, and use of pertinent drug therapy), and medical insurance were analyzed according to gender, Hispanic and NHW race/ethnicity when AMI was confirmed. For categorical variables, 2 × 2 chi-square analysis was conducted. Odds ratio and 95% confidence interval for outcomes adjusted for gender, race/ethnicity, cardiovascular risk factors, and insurance were obtained. Results. Women and Hispanics had similar drug therapy, CATH, PCI, and mortality as men and NHW when AMI was confirmed (n = 387). Hispanics had less private insurance than NHW (31.4% versus 56.3%, P < 0.001); no significant differences were found according to gender. Conclusions. No differences in quality measures and outcomes were found for women and between Hispanic and NHW in AMI patients admitted to a facility with a large Hispanic representation. Disparities in medical insurance showed no influence on these findings.

Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities

Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called "implicit bias". All of society is susceptible to these biases, including physicians. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making. We then present the bias-reducing strategies of consciously taking patients' perspectives and intentionally focusing on individual patients' information apart from their social group. We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care. We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.

Care and outcomes of Asian-American acute myocardial infarction patients: findings from the American Heart Association Get With The Guidelines-Coronary Artery Disease program

BACKGROUND

Asian-Americans represent an important United States minority population, yet there are limited data regarding the clinical care and outcomes of Asian-Americans following acute myocardial infarction (AMI). Using data from the American Heart Association Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program, we compared use of and trends in evidence-based care AMI processes and outcome in Asian-American versus white patients.

METHODS AND RESULTS

We analyzed 107,403 AMI patients (4412 Asian-Americans, 4.1%) from 382 United States centers participating in the Get With The Guidelines-Coronary Artery Disease program between 2003 and 2008. Use of 6 AMI performance measures, composite "defect-free" care (proportion receiving all eligible performance measures), door-to-balloon time, and in-hospital mortality were examined. Trends in care over this time period were explored. Compared with whites, Asian-American AMI patients were significantly older, more likely to be covered by Medicaid and recruited in the west region, and had a higher prevalence of diabetes, hypertension, heart failure, and smoking. In-hospital unadjusted mortality was higher among Asian-American patients. Overall, Asian-Americans were comparable with whites regarding the baseline quality of care, except that Asian-Americans were less likely to get smoking cessation counseling (65.6% versus 81.5%). Asian-American AMI patients experienced improvement in the 6 individual measures (P≤0.048), defect-free care (P<0.001), and door-to-balloon time (P<0.001). The improvement rates were similar for both Asian-Americans and whites. Compared with whites, the adjusted in-hospital mortality rate was higher for Asian-Americans (adjusted relative risk: 1.16; 95% confidence interval: 1.00-1.35; P=0.04).

CONCLUSIONS

Evidence-based care for AMI processes improved significantly over the period of 2003 to 2008 for Asian-American and white patients in the Get With The Guidelines-Coronary Artery Disease program. Differences in care between Asian-Americans and whites, when present, were reduced over time.

Racial and Ethnic Differences in the Treatment of Acute Myocardial Infarction

Background— Racial/ethnic differences in cardiovascular care have been well documented. We sought to determine whether racial/ethnic differences in evidence-based acute myocardial infarction care persist among hospitals participating in a national quality improvement program.

Methods and Results— We analyzed 142 593 acute myocardial infarction patients (121 528 whites, 10 882 blacks, and 10 183 Hispanics) at 443 hospitals participating in the Get With the Guidelines–Coronary Artery Disease (GWTG-CAD) program between January 2002 and June 2007. We examined individual and overall composite rates of defect-free care, defined as the proportion of patients receiving all eligible performance measures. In addition, we examined temporal trends in use of performance measures according to race/ethnicity by calendar quarter. Overall, individual performance measure use was high, ranging from 78% for use of angiotensin-converting enzyme inhibitors to 96% for use of aspirin at discharge. Use of each of these improved significantly over the 5 years of study. Overall, defect-free care was 80.9% for whites, 79.5% for Hispanics (adjusted odds ratio versus whites 1.00, 95% confidence interval 0.94 to 1.06, P =0.94), and 77.7% for blacks (adjusted odds ratio versus whites 0.93, 95% confidence interval 0.87 to 0.98, P =0.01). A significant gap in defect-free care was observed for blacks mostly during the first half of the study, which was no longer present during the remainder of the study. Overall, progressive improvements in defect-free care were observed regardless of race/ethnic groups.

Conclusions— Among hospitals engaged in a national quality monitoring and improvement program, evidence-based care for acute myocardial infarction appeared to improve over time for patients irrespective of race/ethnicity, and differences in care by race/ethnicity care were reduced or eliminated.

Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006

BACKGROUND

Trends in the use of guideline-based treatment for acute myocardial infarction (AMI) as well as its association with patient outcomes have not been summarized in a large, longitudinal study. Furthermore, it is unknown whether gender-, race-, and age-based care disparities have narrowed over time.

METHODS AND RESULTS

Using the National Registry of Myocardial Infarction database, we analyzed 2,515,106 patients with AMI admitted to 2,157 US hospitals between July 1990 and December 2006 to examine trends overall and in select subgroups of guideline-based admission, procedural, and discharge therapy use. The contribution of temporal improvements in acute care therapies to declines in in-hospital mortality was examined using logistic regression analysis. From 1990 to 2006, the use of all acute guideline-recommended therapies administered rose significantly for patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction but remained below 90% for most therapies. Cardiac catheterization and percutaneous coronary intervention use increased in patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction, whereas coronary bypass surgery use declined in both groups. Despite overall care improvements, women, blacks, and patients > or =75 years old were significantly less likely to receive revascularization or discharge lipid-lowering therapy relative to their counterparts. Temporal improvements in acute therapies may account for up to 37% of the annual decline in risk for in-hospital AMI mortality.

CONCLUSION

Adherence to American Heart Association/American College of Cardiology practice guidelines has improved care of patients with AMI and is associated with significant reductions in in-hospital mortality rates. However, persistent gaps in overall care as well as care disparities remain and suggest the need for ongoing quality improvement efforts.

Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006

BACKGROUND

Although ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (AMI) have been the focus of intense clinical investigation, limited information exists on characteristics and hospital mortality of patients not enrolled in clinical trials. Previous large databases have reported declining mortality of patients with STEMI but have not noted substantial mortality change among those with NSTEMI.

METHODS

The National Registry of Myocardial Infarction enrolled 2,515,106 patients at 2,157 US hospitals from 1990 to 2006. Of these, we evaluated 1,950,561 with diagnoses reflecting acute myocardial ischemia on admission.

RESULTS

From 1990 to 2006, the proportion of NSTEMI increased from 14.2% to 59.1% (P < .0001), whereas the proportion of STEMI decreased. Mean age increased (from 64.1 to 66.4 years, P < .0001) as did the proportion of females (from 32.4% to 37.0%, P < .0001). Patients were less likely to report prior angina, prior AMI, or family history of coronary artery disease but more likely to report history of diabetes, hypertension, current smoking, heart failure, prior revascularization, stroke, and hyperlipidemia. From 1994 to 2006, hospital mortality fell among all patients (10.4% to 6.3%), STEMI (11.5% to 8.0%), and NSTEMI (7.1% to 5.2%), (all P < .0001). After adjustment for baseline covariates, hospital mortality fell among all patients by 23.6% (odds ratio [OR] 0.764, 95% CI 0.744-0.785), STEMI by 24.2% (OR 0.758, 0.732-0.784), and NSTEMI by 22.6% (OR 0.774, 0.741-0.809), all P < .001.

CONCLUSIONS

This large, observational database from 1990 to 2006 shows increasing prevalence of NSTEMI and, despite higher risk profile on presentation, falling risk-adjusted hospital mortality in patients with either STEMI or NSTEMI.

Preferences for cardiac tests and procedures may partially explain sex but not race disparities

OBJECTIVE

There are known race and sex differences in emergent cardiac care. Many feel these differences reflect a bias from the physician. We hypothesized these differences may be the result of patient preferences.

METHODS

Emergency department (ED) patients 40 years and older with a chief complaint of chest pain were surveyed from July 11 through December 9, 2005, at 2 academic EDs. This prospective survey study included demographics and prior cardiac test experience. Preferences for hypothetical cardiac tests and procedures were compared between race and sex using chi(2) or Fisher exact tests.

RESULTS

Two hundred sixteen patients were enrolled. The mean age was 55 +/- 12 years (43% men and 51% black). Blacks compared with whites preferred the electrocardiogram (ECG) to the technetium-99m sestamibi (MIBI) stress test. Blacks also preferred a percutaneous coronary intervention (PCI) compared with whites who were more likely to forego PCI. These racial differences disappeared when a physician recommended a procedure. There were no race preferences between PCI vs coronary artery bypass graft, whether or not a doctor recommended the procedure. For sex, there were no preferences between ECG vs MIBI stress test or cardiac catheterization, whether or not a doctor recommended the test or procedure. With regard to a choice between PCI and coronary artery bypass graft, women were more likely to decline the procedure than men. Even with a physician-recommended procedure, women were more likely to refuse than men, whereas men were more likely to accept it.

CONCLUSIONS

Blacks were more likely to prefer the less invasive stress test and wanted PCIs more, but these racial differences disappeared when a physician-recommended test was offered. Women were more likely to refuse the most invasive cardiac procedure compared with men. The sex-related preferences might partially explain why women receive fewer invasive cardiac procedures than men. However, race-related cardiac preferences suggest that other factors beyond patient preference account for fewer PCIs in black patients.

Ethnicity and socioeconomic status influence use of primary angioplasty in patients presenting with acute myocardial infarction

BACKGROUND

Primary percutaneous coronary intervention (PCI) has become an important treatment for patients (pts) with acute myocardial infarction (AMI). Whether ethnic and socioeconomic disparities exist in use of primary PCI for AMI is unknown.

METHODS

Patients hospitalized for transmural AMI in Pennsylvania from January 2003 through June 2004 (n = 16985) were studied. Patient clinical characteristics, insurance status, and hospital type were analyzed using multiple logistic regression analysis to assess the independent correlates of PCI on the day of admission for AMI.

RESULTS

Among 16,985 pts, primary PCI was performed in 6934 (46%) of 14,944 whites, 363 (40%) of 910 African Americans, and 618 (55%) of 1131 other ethnicities. Primary PCI was associated positively with younger age, male sex, known dyslipidemia, and prior PCI (all P < .03), and negatively with diabetes, renal failure, prior myocardial infarction or bypass surgery, and higher predicted death by the Mediqual Atlas Outcomes score (all P < .01). After adjustment for these variables, African American ethnicity (odds ratio 0.78, 95% confidence interval 0.67-0.91), lowest income quintile, (odds ratios 0.87, 95% confidence interval 0.80-0.94), lack of commercial insurance, and nonurban and for-profit hospital status were independently associated with not undergoing primary PCI (all P < .003).

CONCLUSION

In a large statewide database of pts with ST-segment elevation AMI, primary PCI was used less often in African American and in lower-income pts, independent of clinical, hospital, and insurance characteristics, identifying persisting disparities in application of advanced cardiac care in traditionally underserved segments of the population.

Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients

CONTEXT

Studies documenting racial/ethnic disparities in health care frequently implicate physicians' unconscious biases. No study to date has measured physicians' unconscious racial bias to test whether this predicts physicians' clinical decisions.

OBJECTIVE

To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes.

DESIGN, SETTING, AND PARTICIPANTS

An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient.

MAIN OUTCOME MEASURES

IAT scores (normal continuous variable) measuring physicians' implicit race preference and perceptions of cooperativeness. Physicians' attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians' explicit racial biases by questionnaire.

RESULTS

Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians' prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009).

CONCLUSIONS

This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians' unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.

Secondary prevention outcomes among black and white cardiac rehabilitation patients

BACKGROUND

Disparities in coronary heart disease and related risk factors persist. It is unknown if cardiac rehabilitation (CR) narrows the gap in risk factor control between black and white patients. Thus, we compared baseline characteristics and secondary prevention outcomes between black and white CR patients.

METHODS

Data from patient records (n = 616, mean age 62 +/- 10 years, 29% women, 25% black) collected between January 1996 and June 2006 were examined. Comparisons were made between Blacks and Whites for baseline characteristics, changes in secondary prevention measures during CR, and the proportion of patients at treatment goals before and after CR. General linear regression modeling was used to determine the effect of race/ethnicity on outcomes.

RESULTS

At baseline, Blacks had more hypertension and diabetes and more adverse measures for blood pressure, low-density lipoprotein and non-high-density lipoprotein cholesterol (non-HDL-C), hemoglobin A1c, 6-minute walk distance, and Short-Form Health Survey (SF-36) physical component score. At CR completion, improvement (P < .05) was achieved among whites in all measures except for HDL-C and systolic blood pressure. Among Blacks, improvement did not reach significance for HDL-C, body mass index, waist circumference, and hemoglobin A1c (when diabetes was present). When adjusting for age, gender, number of sessions attended, and baseline measure, Whites improved more than Blacks in 6-minute walk distance, self-reported physical activity, body mass index, waist circumference, low-density lipoprotein cholesterol, and hemoglobin A1c (all P < .05).

CONCLUSION

Blacks entered CR with more adverse risk factor measures compared with Whites. Although both groups gained secondary prevention benefits, the degree of improvement was less for Blacks than Whites, and this was especially evident among black women.

Racial differences among high-risk patients presenting with non-ST-segment elevation acute coronary syndromes (results from the SYNERGY trial)

Management and outcomes of patients with acute coronary syndromes (ACSs) may vary according to patient race and ethnicity. To assess racial differences in presentation and outcome in high-risk North American patients with non-ST-segment elevation (NSTE) ACS, we analyzed baseline racial/ethnic differences and all-cause death or nonfatal myocardial infarction (MI) in 6,077 white, 586 African-American, and 344 Hispanic patients through 30-day, 6-month, and 1-year follow-up. Frequencies of hypertension were 66% for whites, 83% for African-Americans, and 78% for Hispanics (overall p <0.001). Use of angiography was similar across groups. Use of percutaneous coronary intervention (46% for whites, 41% for African-Americans, and 45% for Hispanics, overall p = 0.046) and coronary artery bypass grafting (20% for whites, 16% for African-Americans, and 22% for Hispanics, overall p = 0.044) differed. African-American patients had significantly fewer diseased vessels compared with white patients (p = 0.0001). Thirty-day death or MI was 14% for whites, 10% for African-Americans, and 14% for Hispanics (overall p = 0.034). After adjustment for baseline variables, African-American patients had lower 30-day death or MI compared with white patients (odds ratio 0.73, 95% confidence interval 0.55 to 0.98). There were no differences in 6-month death or MI across racial/ethnic groups. In conclusion, baseline clinical characteristics differed across North American racial/ethnic groups in the SYNERGY trial. African-American patients had significantly better adjusted 30-day outcomes but similar 6-month outcomes compared with white patients.

Disparities in the emergency department evaluation of chest pain patients

BACKGROUND

The existence of race and gender differences in the provision of cardiovascular health care has been increasingly recognized. However, few studies have examined whether these differences exist in the emergency department (ED) setting.

OBJECTIVES

To evaluate race, gender, and insurance differences in the receipt of early, noninvasive diagnostic tests among persons presenting to an ED with a complaint of chest pain.

METHODS

Data were drawn from the U.S. National Hospital Ambulatory Health Care Survey of EDs. Visits made during 1995-2000 by persons aged 30 years or older with chest pain as a reason for the visit were included. Factors affecting the likelihood of ordering electrocardiography, cardiac monitoring, oxygen saturation measurement using pulse oximetry, and chest radiography were analyzed using multivariate probit analysis.

RESULTS

A total of 7,068 persons aged 30 years or older presented to an ED with a primary complaint of chest pain during the six-year period, corresponding to more than 32 million such visits nationally. The adjusted probability of ordering a test was highest for non-African American patients for all tests considered. African American men had the lowest probabilities (74.3% and 62% for electrocardiography and chest radiography, respectively), compared with 81.1% and 70.3%, respectively, among non-African American men. Only 37.5% of African American women received cardiac monitoring, compared with 54.5% of non-African American men. Similarly, African American women were significantly less likely than non-African American men to have their oxygen saturation measured. Patients who were uninsured or self-pay, as well as patients with "other" insurance, also had a lower probability than insured persons of having these tests ordered.

CONCLUSIONS

This study documents race, gender, and insurance differences in the provision of electrocardiography and chest radiography testing as well as cardiac rhythm and oxygen saturation monitoring in patients presenting with chest pain. These observed differences should catalyze further study into the underlying causes of disparities in cardiac care at an earlier point of patient contact with the health care system.

The influence of race and gender on time to initial electrocardiogram for patients with chest pain

OBJECTIVES

To determine whether race or gender affected time to initial electrocardiogram (ECG) for patients who presented to an emergency department with chest pain.

METHODS

This was a prospective cohort study of patients with chest pain. Patients were divided into three groups based on final diagnosis of acute myocardial infarction or unstable angina and all others with noncardiac chest pain. Data were analyzed using ranks in a two-way analysis of covariance adjusted for age.

RESULTS

A total of 4,358 patients were studied; 58.6% were women and 41.4% men, and 70.3% were African American, 26.0% white, and 3.6% other. Overall, nonwhite patients had longer times to initial ECG compared with white patients. These effects were consistent regardless of ultimate diagnosis. Overall, women had longer times to initial ECG than men. However, ECG time differed by final diagnosis. There were no differences in time to ECG for women compared with men with acute myocardial infarction or unstable angina, but women received an ECG significantly slower than men for noncardiac chest pain.

CONCLUSIONS

The first screening test for acute coronary syndrome, the ECG, took longer to obtain for nonwhite patients, regardless of final diagnosis. This was unfortunately consistent with the literature that shows racial disparities in all aspects of emergent cardiac care. For women, the overall delay in ECG time can be explained by delays for those women with noncardiac chest pain.

Training community health workers to reduce health disparities in Alabama's Black Belt: the Pine Apple Heart Disease and Stroke Project

African American women have significantly higher mortality rates from heart disease and stroke than White women despite advances in treatment and the management of risk factors. Community health workers (CHWs) serve important roles in culturally relevant programs to prevent disease and promote health. This article describes the Pine Apple Heart and Stroke Project's activities to (1) revise the Women's Wellness Sourcebook Module III: Heart and Stroke to be consistent with national guidelines on heart disease and stroke and to meet the needs of African American women living in rural southern communities; (2) train CHWs using the revised curriculum; and (3) evaluate the training program. Revisions of the curriculum were based on recommendations by an expert advisory panel, the staff of a rural health clinic, and feedback from CHWs during training. Questionnaires after training revealed positive changes in CHWs' knowledge, attitudes, self-efficacy, and self-reported risk reduction behaviors related to heart disease, stroke, cancer, and patient-provider communication. This study provides a CHW training curriculum that may be useful to others in establishing heart disease and stroke programs in rural underserved communities.

Cardiac procedure use following acute myocardial infarction among American Indians

BACKGROUND

The prevalence of coronary heart disease is rising among American Indians (AIs), but there is limited evidence describing processes of care for AI with acute myocardial infarction (AMI). We compared rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery between AI and whites with AMI.

METHODS

Using data from the Nationwide Inpatient Sample and the Indian Health Service National Patient Information Reporting System, we identified 2511 AI and 316,526 whites older than 30 years admitted with AMI during 1998 to 2001. Comparisons of cardiac procedure use between AI and whites were performed after adjusting for comorbid conditions and after stratifying by geographic region.

RESULTS

American Indians were less likely than whites to undergo cardiac catheterization and PCI in 3 of 4 geographic regions, with the largest difference occurring in the West South Central region (OR 0.32, 95% CI 0.24 to 0.43 for catheterization; OR 0.43, 95% CI 0.31 to 0.57 for PCI). American Indians were less likely than whites to undergo CABG surgery among diabetic patients (OR 0.48, 95% CI 0.32-0.73), but not among nondiabetic patients (OR 0.90, 95% CI 0.72-1.12). There were no differences in rates of PCI and CABG surgery between AIs and whites among those receiving cardiac catheterization.

CONCLUSIONS

Differences in the performance of coronary procedures are concentrated in western regions of the United States and are especially related to access to cardiac catheterization. Future studies are indicated to elucidate the mechanisms of these differences in care and their impact on clinical outcomes.

Differences in Triage Thresholds for Patients Presenting with Possible Acute Coronary Syndromes

BACKGROUND

Many studies have shown differences in cardiac care by racial/ethnic groups without accounting for institutional factors at the location of care.

OBJECTIVE

Exploratory analysis of the effect of hospital funding status (public vs private) on emergency department (ED) triage decision making for patients with symptoms suggestive of acute coronary syndromes (ACSs) and on the likelihood of ED discharge for patients with confirmed ACS.

STUDY DESIGN AND SETTING

Secondary analysis of data from a randomized controlled trial of 10,659 ED patients with possible ACS in five urban academic public and five private hospitals. The main outcome measures were the sensitivity and specificity of hospital admission for the presence of ACS at public and private hospitals and the adjusted odds of a patient with ACS not being hospitalized at public versus private hospitals.

RESULTS

Of 10,659 ED patients, 1,856 had confirmed ACS. For patients with suspected ACS, triage decisions at private hospitals were considerably more sensitive (99 vs 96%; p<.001) but less specific (30 vs 48%; p<.001) than at public hospitals. The difference between hospital types persisted after adjustment for multiple patient-level and hospital-level characteristics.

CONCLUSION

Significant differences in triage for patients with suspected ACS exist between public and private hospital EDs, even after adjustment for multiple patient demographic, clinical, and institutional factors. Further studies are needed to clarify the causes of the differences.

Differences in the clinical features and outcomes in African Americans and whites with myocardial infarction

PURPOSE

Less is known about the differences in clinical and angiographic features and the outcomes of African Americans with ST-elevation myocardial infarction compared with whites with ST-elevation myocardial infarction. Accordingly, the current study examines the relationship of African American race to patient-related clinical factors, angiographic findings, and clinical events.

METHODS

We evaluated data from 32419 patients with ST-elevation myocardial infarction who received fibrinolysis. The primary outcomes of interest were 30-day and 5-year mortality.

RESULTS

African Americans comprised 5.1% of the study population (1664/32419). Compared with white patients, black patients were younger, were more likely female, had a higher prevalence of coronary risk factors, and were more likely to have higher presenting heart rate, blood pressure, and Killip Class. Coronary angiography rates were similar in the two groups, but blacks were less likely to undergo coronary revascularization. The patency of the infarct-related artery after thrombolysis or mechanical reperfusion was higher in blacks, who were more likely to have no significant coronary artery disease and less likely to have disease in two or more vessels. In-hospital stroke (adjusted odds ratio 1.75, 95% confidence interval [CI] 1.19-2.59) and major bleeding (adjusted odds ratio 1.32, 95% CI 1.13-1.55) were higher among African Americans. Although no differences were observed in the 30-day mortality between the two groups, African Americans who survived to 30 days had higher 5-year mortality than whites (17% vs 12.5%, adjusted hazard ratio 1.63, 95% CI 1.41-1.90).

CONCLUSIONS

Although 30-day survival was similar between African Americans and whites with ST-elevation myocardial infarction, in-hospital stroke and bleeding and 5-year mortality among 30-day survivors were significantly higher among blacks despite their younger age.

Diabetes status and racial differences in post-myocardial infarction mortality

BACKGROUND

Prior studies regarding the effect of racial status on post-myocardial infarction (MI) in subjects with diabetes have yielded conflicting results. We evaluated the effect of diabetes status on racial differences in post-MI mortality and morbidity for a 7-year period, from 1990 through 1997.

METHODS

All patients discharged with the primary diagnosis of acute MI from any Veterans Affairs Medical Center in the country between October 1990 and September 1997 were identified. Demographic, comorbid conditions, inpatient, outpatient, mortality, and readmission data were extracted. Mortality, revascularization, readmissions, and length of hospital stay for MI were compared for the group with diabetes and that without diabetes. Comparison was made between black and white patients. Independent predictors of survival using a Cox regression model were examined.

RESULTS

We identified 67,889 patients with MI of whom 17,756 (26%) had diabetes. Race status was known for 66,506 subjects of whom 55,731 (84%) were white and 8437 (13%) were black. Regardless of the race, the diabetic patients tended to have higher mortality than nondiabetic patients. The post-MI mortality during the entire follow-up period tended to be similar between blacks and whites for the nondiabetic patients, whereas the mortality tended to be lower in blacks than in whites in diabetic patients.

CONCLUSIONS

Mortality from post-MI is significantly lower in blacks with diabetes than in whites with diabetes. In contrast, no racial difference in long-term mortality was seen among subjects without diabetes. Thus, it appears that diabetes status determines racial variation in post-MI mortality. The reasons for better survival post-MI of blacks in general and among subjects with diabetes in particular need to be further investigated.

Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients

BACKGROUND

African Americans are more likely to be seen by physicians with less clinical training or to be treated at hospitals with longer average times to acute reperfusion therapies. Less is known about differences in health outcomes. This report compares risk-adjusted mortality after acute myocardial infarction (AMI) between US hospitals with high and low fractions of elderly black AMI patients.

METHODS AND RESULTS

A prospective cohort study was performed for fee-for-service Medicare patients hospitalized for AMI during 1997 to 2001 (n=1,136,736). Hospitals (n=4289) were classified into approximate deciles depending on the extent to which the hospital served the black population. Decile 1 (12.5% of AMI patients) included hospitals without any black AMI admissions during 1997 to 2001. Decile 10 (10% of AMI patients) included hospitals with the highest fraction of black AMI patients (33.6%). The main outcome measures were 90-day and 30-day mortality after AMI. Patients admitted to hospitals disproportionately serving blacks experienced no greater level of morbidities or severity of the infarction, yet hospitals in decile 10 experienced a risk-adjusted 90-day mortality rate of 23.7% (95% CI 23.2% to 24.2%) compared with 20.1% (95% CI 19.7% to 20.4%) in decile 1 hospitals. Differences in outcomes between hospitals were not explained by income, hospital ownership status, hospital volume, census region, urban status, or hospital surgical treatment intensity.

CONCLUSIONS

Risk-adjusted mortality after AMI is significantly higher in US hospitals that disproportionately serve blacks. A reduction in overall mortality at these hospitals could dramatically reduce black-white disparities in healthcare outcomes.

Racial and ethnic differences in the treatment and outcome of cardiogenic shock following acute myocardial infarction

We investigated the association between race/ethnicity on the use of cardiac resources in patients who have acute myocardial infarction that is complicated by cardiogenic shock. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial examined the effect of reperfusion and revascularization treatment strategies on mortality. Patients screened but not enrolled in the SHOCK Trial (n = 1,189) were entered into the SHOCK registry. Of the patients in the United States registry (n = 538) who had shock due to predominant left ventricular failure, 440 were characterized as white (82%), 42 as Hispanic (8%), 34 as African-American (6%), and 22 as Asian/other (4%). The use of invasive procedures differed significantly by race/ethnicity. Hispanic patients underwent coronary angiography significantly less often than did white patients (38 vs 66%, p = 0.002). Among those patients who underwent coronary angiography, there were no race/ethnicity differences in the proportion of patients who underwent revascularization (p = 0.353). Overall in-hospital mortality (57%) differed significantly by race/ethnicity (p = 0.05), with the highest mortality rate in Hispanic patients (74% vs 65% for African-Americans, 56% for whites, and 41% for Asian/other). After adjustment for patient characteristics and use of revascularization, there were no mortality differences by race/ethnicity (p = 0.262), with all race/ethnicity subgroups benefiting equally by revascularization. In conclusion, the SHOCK registry showed significant differences in the treatment and in-hospital mortality of Hispanic patients who had cardiogenic shock, with these patients being less likely to undergo percutaneous coronary intervention. Therefore, early revascularization should be strongly considered for all patients, independent of race/ethnicity, who develop cardiogenic shock after acute myocardial infarction.

Influence of racial disparities in procedure use on functional status outcomes among patients with coronary artery disease

BACKGROUND

Although black cardiac patients receive fewer revascularization procedures than whites, it is unclear whether this has a detrimental impact on outcomes. The objective of our study was to compare 6-month functional status and angina outcomes among blacks and whites with documented coronary disease and to assess whether differential use of revascularization procedures affects these outcomes.

METHODS AND RESULTS

We identified a prospective cohort of 1534 white and 337 black patients undergoing cardiac catheterization between August 1998 and April 2001. Health status was assessed at baseline and 6 months with the Short-Form 36 (SF-36) Health Survey and the Seattle Angina Questionnaire (SAQ) Angina Frequency Scale. Compared with whites, blacks received fewer coronary revascularization procedures (52.5% versus 66.0%; P<0.01). By 6 months, blacks had similar mortality (odds ratio, 1.03; 95% CI, 0.57 to 1.9) but worse scores in 5 SF-36 domains (physical, social, role physical, role emotional, and mental health function). Blacks also reported higher rates of angina at 6 months than whites (34.2% versus 24.6%; P<0.01). After adjustment for baseline functional status and clinical and demographic variables, blacks had significantly worse summary physical component scores, summary mental component scores, and SAQ Angina Frequency Scale scores. However, differences in physical component summary scores and SAQ scores between blacks and whites were no longer significant after adjustment for revascularization status.

CONCLUSIONS

Our study is among the first to document greater symptoms and functional impairment among black cardiac patients relative to whites. Differential use of coronary revascularization may contribute to the poorer functional outcomes observed among black patients with documented coronary disease.

Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?)

BACKGROUND

Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes.

METHODS AND RESULTS

Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37,813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, beta-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients.

CONCLUSIONS

Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.

Issues in minority health: atherosclerosis and coronary heart disease in African Americans

Cardiovascular disease (in particular, CHD) is the leading cause of death in the United States for Americans of both sexes and of all racial and ethnic backgrounds. African Americans have the highest overall CHD mortality rate and the highest out-of-hospital coronary death rate of any ethnic group in the United States, particularly at younger ages. Contributors to the earlier onset of CHD and excess CHD deaths among African Americans include a high prevalence of coronary risk factors, patient delays in seeking medical care, and disparities in health care. The clinical spectrum of acute and chronic CHD in African Americans is the same as in whites; however, African Americans have a higher risk of sudden cardiac death and present clinically more often with unstable angina and non-ST-segment elevation myocardial infarction than whites. Although generally not difficult, the accurate diagnosis and risk assessment for CHD in African Americans may at times present special challenges. The high prevalence of hypertension and type 2 diabetes mellitus may contribute to discordance between symptomatology and the severity of coronary artery disease, and some noninvasive tests appear to have a lower predictive value for disease. The high prevalence of modifiable risk factors provides great opportunities for the prevention of CHD in African Americans. Patients at high risk should be targeted for intensive risk reduction measures, early recognition/diagnosis of ischemic syndromes, and appropriate referral for coronary interventions and cardiac surgical procedures. African Americans who have ACSs receive less aggressive treatment than their white counterparts but they should not. Use of evidence-based therapies for management of patients who have ACSs and better understanding of various available treatment strategies are of utmost importance. Reducing and ultimately eliminating disparities in cardiovascular care and outcomes require comprehensive programs of education and advocacy(Box 4) with the goals of (1) increasing provider and public awareness of the disparities in treatment; (2) decreasing patient delays in seeking medical care for acute myocardial infarction and other cardiac disorders; (3) more timely and appropriate therapy for ACSs; (4) improved access to preventive, diagnostic, and interventional cardiovascular therapies; (5) more effective implementation of evidence-based treatment guidelines; and (6) improved physician-patient communications.

Patient cues that predict nurses' triage decisions for acute coronary syndromes

The purpose of this study was to determine the patient cues that emergency department (ED) nurses use to triage male and female patients with complaints suggestive of acute coronary syndromes (ACSs) and to determine if cues used by ED nurses to make clinical inferences varied by patient sex or nurses' demographic characteristics. Using clinical vignette questionnaires with different patient characteristics, ED nurses' triage decisions were evaluated to determine the patient cues used to predict ACS. Men and women were equally likely to be given an ACS triage decision and this was not affected by nurses' demographic characteristics. However, nurses used different cues to triage men and women with complaints suggestive of ACS, although by receiver operating characteristic curves, the differences between sexes were small. In addition, female vignette patients were more likely than male vignette patients to be assigned a suspected cause of cholecystitis for their presentation in a small subset of 13 (11:2; odds ratio, 1.653; 95% confidence interval, 1.115-24.47; p=.036). This study provides insight into the complex phenomenon of triage decision making and warrants further exploration.

Performance of a population-based cardiac risk stratification tool in Asian patients with chest pain

OBJECTIVES

Most contemporary cardiac risk stratification tools have been derived and validated in mixed-race populations. Their validity in single-race populations has not been tested. The authors sought to compare the performance of a risk stratification tool between a mixed-race U.S. patient population and an Asian patient population.

METHODS

This study is an analysis of data from the Internet Tracking Registry for Acute Coronary Syndromes (i(*)trACS) registry of patients with chest pain presenting to the emergency departments of eight U.S. centers and one site in Singapore. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) was computed for included patients, and its performance in predicting acute coronary syndrome (ACS) was compared between patients from the United States and Singapore.

RESULTS

Of the 11,991 included patients, 1,120 experienced ACS. Although the ACI-TIPI demonstrated similar accuracy among groups (area under the curve, 0.729 [U.S.] vs. 0.719 [Singapore]; p = 0.5611), sensitivity and specificity were different when equal ACI-TIPI thresholds were considered. Recreating the logistic regression models used to create the ACI-TIPI showed similar results between the derived parameters and the parameters estimated for the U.S. group. In contrast, age older than 50 years (log-odds ratio [LOR], 0.107; 95% confidence interval [CI] = 0.518 to 0.713), male gender (LOR, 0.487; 95% CI = 0.149 to 1.122), and chest pain as a primary complaint (LOR, 0.237; 95% CI = 0.139 to 0.613) had little predictive power in patients from Singapore.

CONCLUSIONS

Differences exist in presentation and factors associated with ACS among patients from the United States and Singapore that may affect the performance of risk stratification tools. These findings suggest that cardiac clinical decision rules need international validation.

Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities

PURPOSE

The use of do-not-resuscitate (DNR) orders may differ by sex or ethnicity, and DNR status may be associated with outcomes for hospitalized patients. Thus, we sought to determine whether differences in rates of DNR by sex and ethnicity influenced differences in mortality.

SUBJECTS AND METHODS

We included all patients admitted to nonfederal California hospitals in 1999 with stroke, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, chronic renal failure, angina, or diabetes mellitus. Rates of physician orders for DNR written within 24 hours of hospital admission and in-hospital mortality were compared between sexes and ethnicities after adjustment for age, admission source and diagnosis, payment type, and comorbidity scores in multivariable logistic regression models.

RESULTS

Of 327890 patients included, 25196 (7.7%) had DNR orders. In adjusted models, women were more likely to have DNR orders than men (odds ratio [OR] 1.19; 95% confidence interval 1.16-1.23; P <0.001) and non-Hispanic whites were more likely to have DNR orders than other ethnicities (OR 1.75; 1.69-1.82; P <0.001). Overall, 13549 (4.1%) patients died in the hospital. Risk of death was greater in those with a DNR order (OR 7.0; 6.7-7.3; P <0.001). Non-Hispanic whites appeared to have a greater risk of in-hospital death in adjusted models (OR 1.09; 1.04-1.12; P <0.001) when DNR status was ignored; however, the risk of death appeared to be lower in non-Hispanic whites in the complete model with DNR included (OR 0.94; 0.90-0.99; P = 0.01). A survival advantage for women was also more apparent after including DNR status in the adjusted model.

CONCLUSIONS

Women and non-Hispanic whites are more likely to have DNR orders. DNR status affected the measurement of sex-ethnic differences in mortality risk.

Relation of age and race with hospital death after acute myocardial infarction

BACKGROUND

Prior studies have suggested that young blacks with acute myocardial infarction (AMI) may have higher hospital mortality rates than whites of similar age. However, the influence of age and race on short-term death has not been explored in detail. We examined the relation of age and race on short-term death in a large AMI population and ascertained the factors that may have contributed to differences in mortality rates.

METHODS

We compared the crude and adjusted hospital mortality rates stratified by age among 40,903 blacks and 501,995 whites with AMI enrolled in the National Registry of Myocardial Infarction-2 in 1482 participating US hospitals from June 1994 through March 1998.

RESULTS

Overall crude mortality was lower among blacks compared with whites (10.9% vs 12.0%, P <.0001). However, blacks had a significantly higher crude mortality rate compared with the whites in the age groups <65 years (<45 years, and 5-year age groups between 45 and 64 years). There was a statistically significant interaction between age and black race on hospital death (P value for interaction <.001). Each 5-year decrement in age from 85 years was associated with 7.2% higher odds of death in blacks compared with whites (95% CI, 5.7% to 7.6%). After adjusting for differences in the baseline, clinical presentation, early treatment, and hospital characteristics, 5-year decrements in age was still associated with increases in the odds for death in blacks compared with whites (5.4%; 95% CI, 3.6% to 7.2%). This interaction between age and black race was present in both sexes but was stronger among men.

CONCLUSIONS

Blacks younger than 65 years had higher hospital mortality rates compared with whites hospitalized for AMI, and decreasing age was associated with progressively higher risk of hospital death for blacks. Differences in the clinical presentation, early treatment, and hospital characteristics could only partly explain this age-race interaction.

From 1960s Evans County Georgia to present-day Jackson, Mississippi: an exploration of the evolution of cardiovascular disease in African Americans

Cardiovascular disease (CVD) is the No. 1 cause of mortality in the United States and it disproportionately affects African Americans. However, there are earlier reports that African Americans had significantly less CVD than whites. This racial discrepancy in CVD rates was noticed primarily for coronary heart disease (CHD). This issue was examined in the Evans County (Georgia) Cardiovascular Disease Study conducted in the 1960s. It showed that African American men had significantly lower rates of CHD than white men. Over the last couple of decades, the rates of CVD have been declining. However, the rate of decline of CVD in African Americans has not been equal to that seen in whites, such that African Americans now have a disproportionate share of CVD in the United States. In the 1990s, the Jackson Heart Study was designed to explore the reasons for the current racial discrepancy. This articles reviews the findings of the Evans County Study and explores various hypotheses for why CVD in African Americans has evolved from a disease from which African Americans may have been "protected" to one in which they shoulder a disproportionate burden.

Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department

STUDY OBJECTIVE

We determine the frequency of patients presenting without a primary complaint of chest pain who are admitted with acute myocardial infarction (AMI) and identify factors associated with an increased risk of a presentation without chest pain.

METHODS

This was a retrospective, cross-sectional study over a 5-year period (July 1, 1993, to June 30, 1998) of patients presenting to a large urban, public hospital emergency department who were admitted and determined to have an AMI based on International Classification of Diseases, 9th Revision, coding and chart review. Main outcome measures were prevalence of presentation without chest pain and prevalence of other predefined presentations (ie, shortness of breath, cardiac arrest, abdominal pain, dizziness/weakness/syncope) as determined by the primary chief complaint entered on arrival at the ED. We calculated univariate relative risks and multivariate odds ratios (ORs) for presentation without chest pain in women, nonwhite ethnic groups, and older age groups.

RESULTS

Of the 721 cases of diagnosed AMI, 53% (380; 95% confidence interval [CI] 49% to 56%) of patients presented with chest pain. The frequency of other complaints were shortness of breath, 17% (121); cardiac arrest, 7% (50); dizziness/weakness/syncope, 4% (32); abdominal pain, 2% (14); and other, 17% (124). The risk of a presentation without chest pain in a patient with AMI increased with age. The characteristic with the highest risk for a presentation without chest pain in patients with AMI was age older than 84 years old (multivariate OR 5.76; 95% CI 3.06 to 10.83). Women were more likely than men to present without chest pain (multivariate OR 1.59; 95% CI 1.11 to 2.28).

CONCLUSION

Our results demonstrate that patients with AMI commonly present to the ED without a primary initial complaint of chest pain and that the frequency of initial presentations without chest pain in our urban, public hospital is as high or higher than that reported in the general ED population. Heightened awareness of atypical presentations may affect assessment of patients with AMI and provide further focus for research into presentations of acute coronary syndrome other than chest pain.

Perceptions of chest pain differ by race

BACKGROUND

African American patients are less likely to receive thrombolytic therapy and coronary revascularization than are white patients. Delay and clinical presentation may be keys to understanding differences in care.

OBJECTIVE

To determine how symptom recognition and perception influence clinical presentation as a function of race, we characterized symptoms and care-seeking behavior in African American and white patients seen in the ED with chest pain.

METHODS

The prospective study was conducted from April 1999 to September 1999 among patients who were seen in the ED and were admitted or observed in the ED Chest Pain Unit (n = 215). Interviews were conducted within 48 hours with a structured set of questions.

RESULTS

Thirty-one percent of white patients and 8.9% of African American patients were admitted with a diagnosis of acute myocardial infarction (P =.001). African American patients were as likely as white patients to report "typical" objective symptoms but were more likely to attribute their symptoms to a gastrointestinal source rather than a cardiac source (P =.05). Of those patients with the final diagnosis of myocardial infarction (n = 45), 61% of African American patients attributed symptoms to a gastrointestinal source and 11% to a cardiac source, versus 26% and 33%, respectively, for white patients. The median prehospital delay for African American patients was 263 minutes (interquartile range, 120 to 756 minutes), similar to the 247 minutes for white patients (interquartile range, 101 to 825 minutes, P =.72), despite African American patients (80%) being more likely than white patients (66%) to perceive their symptoms as severe/life-threatening at onset (P =.05).

CONCLUSION

Racial differences in symptom perception exist. Although the proportion of objectively defined typical symptoms were similar, self-attribution was more often noncardiac in African American patients than in white patients. Self-attribution, in addition to objective clinical findings, is likely to influence caregiver diagnostic approaches and therefore therapeutic approaches, and merits further study.

The relationship of race/ethnicity and social class to hormone replacement therapy: results from the Third National Health and Nutrition Examination Survey 1988-1994

OBJECTIVE

To use a nationally representative sample to examine the prevalence of hormone replacement therapy (HRT) use and its relationship to different markers of social class in American women 60 years of age and older.

DESIGN

Nationally representative cross-sectional survey with an in-person interview and medical examination. Between 1988 and 1994, 3,479 women aged 60 to 90+ years were examined as part of the National Health and Nutrition Examination Survey III. Mexican Americans, non-Hispanic blacks and much older women were oversampled to produce reliable estimates for these groups.

RESULTS

Overall, the number of women who reported ever having used HRT was 37% [confidence interval (CI), 33%-40%] of all women older than 60 years of age; 40% (CI, 37%-41%) of older, non-Hispanic white women; 20% (CI, 14%-25%) of non-Hispanic black women; and 24% (CI, 20%-29%) of Mexican American women. HRT was used by 43% (CI, 38%-47%) of women 60 to 70 years old, 37% (CI, 32%-41%) of those 71 to 80 years old, and 20% (CI, 13%-26%) of women older than 80. HRT use was lowest among women who did not complete high school or among those in the lowest family income categories. Among women more than 60 years old who reported having a hysterectomy, 51% (CI, 47%-55%) reported using HRT, whereas only 20% (CI, 17%-23%) of those who had a natural menopause reported using HRT.

CONCLUSIONS

Although many women can benefit from HRT, the number of American women who report they have ever used it remains low. More research is needed to examine the implications of racial differences in compliance, patient and physician attitudes toward HRT, and possible environmental barriers that may prevent use.

Differences between African Americans and whites in the outcome of heart failure: Evidence for a greater functional decline in African Americans

BACKGROUND

National statistics indicate that African Americans are disproportionately affected by mortality and hospitalizations resulting from heart failure when compared with other racial/ethnic groups. This might, in part, reflect a poorer course of heart failure among African Americans.

METHODS

We conducted a prospective cohort study of 316 white and 82 African American consecutive patients aged > or =50 years with decompensated heart failure on hospital admission. The outcome of the study was death or decline in activities of daily living function at 6 months relative to baseline.

RESULTS

African American patients were on average 8 years younger and had less favorable socioeconomic and access-to-care indicators. African Americans more often had a history of hypertension, renal insufficiency, and diabetes, but there were no differences in functional status, self-reported health status, signs of decompensation, or left ventricular ejection fraction. Quality-of-care indicators did not differ by race. Mortality rates at 6 months were similar in African Americans and whites (19.5% vs 17.2%, age adjusted), but African Americans had a greater functional decline (37.6% vs 24.7%). After adjusting for baseline characteristics, African Americans had an almost 50% higher risk of either death or decline in activities of daily living functioning (relative risk 1.45, 95% CI, 1.06-1.81). Adjustment for socioeconomic, access-to-care and quality-of-care indicators did not substantially change this estimate.

CONCLUSIONS

African Americans have similar mortality but greater functional decline than whites after hospitalization for heart failure. This outcome is not explained by clinical, socioeconomic, access-to-care or quality-of-care differences.

Cardiovascular disease among women residing in rural America: epidemiology, explanations, and challenges

Many believe that the United States has entered a "Golden Age" of cardiovascular health and medicine. Pharmacological and technological advances have indeed produced an era of declining mortality rates from cardiovascular diseases for the nation as a whole. However, there remain areas of challenge. Cardiovascular disease (CVD) is still by far the leading cause of death and disability in the United States, and it is the leading killer of US women. Perhaps the single most notable feature of the CVD epidemic in the United States is the substantial difference in morbidity and mortality that exists between White women and women of color, with a disproportionate share of suffering borne by minority women. Unexplained regional variations also cloud the otherwise notable progress of the last 30 years, and many rural areas appear to be uniquely affected by cardiovascular disease. This commentary reviews the evidence that the CVD epidemic disproportionately burdens women of color who reside in rural areas, itemizes and provides a logical framework for explaining this burden, and suggests approaches to solving this vexing public health problem.

Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction

OBJECTIVES

The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system.

DESIGN

Retrospective cohort study using clinical data.

SETTING

Eighty-one acute care VA hospitals.

PATIENTS

Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients.

MAIN OUTCOME MEASURES

Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years.

RESULTS

Black patients were equally likely to receive beta-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%; P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups.

CONCLUSIONS

In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.

Underutilization of reperfusion therapy in eligible African Americans with acute myocardial infarction: Role of presentation and evaluation characteristics

BACKGROUND

Immediate reperfusion therapy to restore coronary blood flow is recommended for all eligible patients with acute myocardial infarction. However, reperfusion therapy is reportedly underutilized among African Americans, even when they are eligible. Reasons for the lack of use have not been fully explored.

METHODS

We examined the demographic, clinical, and treatment data of 10,469 African Americans with acute myocardial infarction who were eligible for reperfusion therapy, enrolled in the National Registry of Myocardial Infarction-2 from June 1994 through March 1998.

RESULTS

The mean age was 62.58 (+/-14.4) years, and 44.7% were female. Although eligible, 47% of the African Americans in this study did not receive reperfusion therapy. In a multivariate analysis, the absence of chest pain at presentation (odds ratio [OR] 0.31, 95% CI 0.26-0.37) and initial admission diagnoses other than definite myocardial infarction (OR for receipt of reperfusion <0.12) were the strongest predictors of lack of early reperfusion therapy. Progressive delays in hospital arrival and hospital evaluation predicted a lower likelihood of early reperfusion. Prior stroke (OR 0.63, 95% CI 0.50-0.78), myocardial infarction (OR 0.75, 95% CI 0.65-0.86), and congestive heart failure (OR 0.49, 95% CI 0.40-0.60) were all associated with lack of reperfusion therapy.

CONCLUSION

Almost half of eligible African American patients with myocardial infarction did not receive reperfusion therapy. Potential reasons may include atypical presentation, patient and institutional delay, and underappreciation of myocardial infarction by care providers. Strategies to address these factors may improve the rate of use of reperfusion therapy.

Racial differences in the use of cardiac catheterization after acute myocardial infarction

BACKGROUND

Several studies have reported that black patients are less likely than white patients to undergo cardiac catheterization after acute myocardial infarction. The role of the race of the physician in this pattern is unknown.

METHODS

We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for acute myocardial infarction in 1994 and 1995, to evaluate whether differences between black patients and white patients in the use of cardiac catheterization within 60 days after acute myocardial infarction varied according to the race of their attending physician.

RESULTS

Our study cohort consisted of 35,676 white and 4039 black patients with acute myocardial infarction who were treated by 17,550 white and 588 black physicians. Black patients had lower rates of cardiac catheterization than white patients, regardless of whether their attending physician was white (rate of catheterization, 38.4 percent vs. 45.7 percent; P< 0.001) or black (38.2 percent vs. 49.6 percent, P<0.001). We did not find a significant interaction between the race of the patients and the race of the physicians in the use of cardiac catheterization. The adjusted mortality rate among black patients was lower than or similar to that among white patients for up to three years after the infarction.

CONCLUSIONS

Racial differences in the use of cardiac catheterization are similar among patients treated by white physicians and those treated by black physicians, suggesting that this pattern of care is independent of the race of the physician.

Race, sex, poverty, and the medical treatment of acute myocardial infarction in the elderly

BACKGROUND

Race, sex, and poverty are associated with the use of diagnostic cardiac catheterization and coronary revascularization during treatment of acute myocardial infarction (AMI). However, the association of sociodemographic characteristics with the use of less costly, more readily available medical therapies remains poorly characterized.

METHODS AND RESULTS

We evaluated 169 079 Medicare beneficiaries >/=65 years of age treated for AMI between January 1994 and February 1996 to determine the association of patient race, sex, and poverty with the use of medical therapy. Multivariable regression models were constructed to evaluate the unadjusted and adjusted influence of sociodemographic characteristics on the use of 2 admission (aspirin, reperfusion) and 2 discharge therapies (aspirin, beta-blockers) indicated during the treatment of AMI. Therapy use varied by patient race, sex, and poverty status. Black patients were less likely to undergo reperfusion (RR 0.84, 95% CI 0. 78, 0.91) or receive aspirin on admission (RR 0.97, 95% CI 0.96, 0. 99) and beta-blockers (RR 0.94, 95% CI 0.88, 1.00) at discharge. Female patients were less likely to receive aspirin on admission (RR 0.98, 95% CI 0.97, 0.99) and discharge (RR 0.98, 95% CI 0.96, 0.99). Poor patients were less likely to receive aspirin (RR 0.97, 95% CI 0. 96, 0.98) or reperfusion (RR 0.97, 95% CI 0.93, 1.00) on admission and aspirin (RR 0.98, 95% CI 0.96, 1.00), or beta-blockers (RR 0.95, 95% CI 0.91, 0.99) on discharge.

CONCLUSIONS

Medical therapies are currently underused in the treatment of black, female, and poor patients with AMI.

Electrocardiographic presentation of blacks with first myocardial infarction does not explain race differences in thrombolysis administration

BACKGROUND

Previous studies have suggested that thrombolysis is used less often in blacks than in whites. However, whether the greater prevalence of contraindications or less specific electrocardiographic manifestations of myocardial infarction (MI) account for this difference is unclear.

METHODS AND RESULTS

We studied 498 consecutive patients (32% blacks) with first MI. Initial electrocardiograms were analyzed, blinded to race and outcome, for ST-segment deviation and bundle branch block to determine eligibility for thrombolysis. The relation of electrocardiographic eligibility for thrombolysis and actual use of thrombolysis in both races was explored. Among blacks, 45% received thrombolysis compared with 66% of whites (P <.001). A similar proportion of blacks and whites were eligible for thrombolysis (59% and 66% respectively, P =. 116), but 62% of electrocardiography-eligible blacks were treated with thrombolysis compared with 75% of whites (P =.016). After accounting for eligibility for electrocardiography and other clinical variables likely to affect the decision to administer thrombolysis by means of conditional logistic regression, blacks were still less likely to receive thrombolysis (relative risk 0.73; 95% confidence interval 0.55 to 0.97).

CONCLUSIONS

We conclude that the differences in thrombolysis administration to blacks and whites are not accounted for by differences in electrocardiographic presentation or other measured variables. Unmeasured differences in clinical presentation of MI may explain racial differences in thrombolysis and merits further study.

A randomized study of direct coronary stent delivery compared with stenting after predilatation: the NIR future trial. On behalf of the NIR Future Trial Investigators

This randomized trial compared a strategy of direct stenting without predilatation (n = 39) with conventional stenting with predilatation (n = 42) in patients with suitable lesions in native vessels > or = 2. 5-mm diameter to be covered by either a 9- or 16-mm-length NIR Primo stent. Equipment cost [mean (median) +/- SD] was less in those with direct stenting [$1,199 (979) +/- 526] than in those with predilatation [$1,455 (1,285) +/- 401, P < 0.001]. There was no significant difference in contrast use or fluoroscopy time. Procedural time was shorter in the direct stenting group. The clinical outcome at 1 month was satisfactory in both groups. In selected patients, a strategy of direct stenting is feasible, costs less, and is quicker to perform than the conventional strategy of stenting following predilatation.

Race, baseline characteristics, and clinical outcomes after coronary intervention: The New Approaches in Coronary Interventions (NACI) registry

BACKGROUND

The impact of race and sex on clinical outcomes after percutaneous coronary interventions remains incompletely understood. Specific data on patient demographics, lesion characteristics, and outcomes of black versus white patients are poorly described. To further evaluate these issues, we analyzed the New Approaches in Coronary Interventions (NACI) registry.

METHODS

Patients (200 black, 4279 white) undergoing coronary interventions in the NACI trial were compared. A Cox proportional hazards model was used to determine which baseline demographics were independent risk factors for the combined end point of death, Q-wave myocardial infarction, and coronary artery bypass grafting at 1 year.

RESULTS

Black patients were significantly younger (age 59 +/- 11 vs 63 +/- 11 years; P <.001), more often obese (29.6 +/- 6 vs 27.5 +/- 4.8 kg/m(2); P <.001), female (50% vs 34%; P <.001), diabetic (34% vs 21%; P <.001), and hypertensive (71% vs 52%; P <.001). Black patients were significantly more likely to have single-vessel disease (48% vs 40%; P <.05) and less likely to have undergone coronary artery bypass grafting (26% vs 34%; P <.05). Blacks were significantly more likely to have a discrete lesion (85% vs 62%; P <. 001) with less thrombus (7% vs 12%; P <.05), tortuosity (17% vs 25%; P <.05), and an ulcerated appearance (5% vs 10%; P <.05). Despite these significant baseline differences, no significant difference was seen in the procedural success (80% vs 82%) or major adverse events (death, Q-wave myocardial infarction, any revascularization) at 1 year (39% vs 34%). Predictors of adverse events for white patients included diabetes (relative risk [RR] = 1.24; confidence intervals [CI], 1.0-1.5) and high-risk status (RR = 1.58; CI, 1.26-1. 91). Predictive characteristics of adverse events for black patients included only sex (RR = 3.45; CI, 1.27-9.35; P =.02).

CONCLUSIONS

There are significant differences in baseline characteristics of black patients compared with white patients. Despite these differences in traditional risk factors, they do not affect procedural success or 1-year outcome. In black patients, only sex predicted adverse events. Additional investigation is required to understand the mechanisms for this difference.