Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry

Impact of Hispanic Ethnicity, Geography, and Insurance Status on Cardiovascular Outcomes in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Hispanics are the largest and fastest growing ethnic minority population in the United States yet are poorly represented in cardiovascular outcomes studies. UC San Diego Health is a primary percutaneous coronary intervention (PCI) center for a diverse group of patients given its proximity to Mexico and underserved rural southeast Imperial County.

OBJECTIVES

The purpose of this study was to study the association between Hispanic ethnicity, geography, insurance status, and PCI outcomes.

METHODS

The UC San Diego Health internal National Cardiovascular Data Registry CathPCI Registry was used to obtain data on patients who underwent PCI from January 2007 to September 2022. Complications and all-cause mortality within 1-year post-PCI were assessed.

RESULTS

A total of 8,295 patients (age 66 years [IQR: 58-75 years], 72% male, 33% Hispanic ethnicity, and 30% from Imperial County) were included. Hispanics and patients from Imperial County irrespective of race or ethnicity had higher body mass index and were more likely to have diabetes, hypertension, hyperlipidemia, end-stage renal disease, and peripheral vascular disease. There was no difference in mortality rates between Hispanic and non-Hispanic Whites in the entire population. However, within Imperial County, Hispanics had significantly higher 30-day (1.4% vs 0.3% P = 0.02), 6-month (2.2% vs 0.8% P = 0.01), and 1-year (2.9% vs 0.9% P = 0.004) mortality rates compared to non-Hispanic Whites. Patients in Imperial County had lower 30-day (1.2% vs 1.9% P = 0.01), 6-month (1.9% vs 3.3% P < 0.001), and 1-year (2.4% vs 5% P < 0.001) mortality rates compared to patients outside of Imperial County. There was no difference in all-cause mortality rates by insurance status in non-Hispanic Whites. Uninsured Hispanic patients had a higher 30-day mortality rate compared to Hispanic patients who had Medicare/Medicaid or private insurance (4.5% vs 2.0% vs 1.0% P = 0.005). Within Imperial County, uninsured Hispanic patients had markedly higher 30-day mortality rate compared to Hispanic patients who had Medicare/Medicaid or private insurance (10.4% vs 1.6% vs 0.3% P < 0.001).

CONCLUSIONS

In socioeconomically disadvantaged areas, Hispanic patients had worse outcomes compared to non-Hispanic Whites compounded by uninsured status. There are complex demographic disparities in PCI outcomes for Hispanic patients and those residing in border zones which need to be recognized and mitigated.

A Review of Racial Differences and Disparities in ECG

The electrocardiogram (ECG) is a widely used, non-invasive tool for diagnosing a range of cardiovascular conditions, including arrhythmia and heart disease-related structural changes. Despite its critical role in clinical care, racial and ethnic differences in ECG readings are often underexplored or inadequately addressed in research. Variations in key ECG parameters, such as PR interval, QRS duration, QT interval, and T-wave morphology, have been noted across different racial groups. However, the limited research in this area has hindered the development of diagnostic criteria that account for these differences, potentially contributing to healthcare disparities, as ECG interpretation algorithms largely developed from major population data may lead to misdiagnoses or inappropriate treatments for minority groups. This review aims to help cardiac researchers and cardiovascular specialists better understand, explore, and address the impact of racial and ethnic differences in ECG readings. By identifying potential causes-ranging from genetic factors to environmental influences-and exploring the resulting disparities in healthcare outcomes, we propose strategies such as the development of race-specific ECG norms, the application of artificial intelligence (AI) to improve diagnostic accuracy, and the diversification of ECG databases. Through these efforts, the medical community can advance toward more personalized and equitable cardiovascular care.

Analysis of the Predictors of Mortality from Ischemic Heart Diseases in the Southern Region of Brazil: A Geographic Machine-Learning-Based Study

Background

Mortality due to ischemic heart disease (IHD) is heterogeneously distributed globally, and identifying the sites most affected by it is essential in developing strategies to mitigate the impact of the disease, despite the complexity resulting from the great diversity of variables involved.

Objective

To analyze the predictability of IHD mortality using machine learning (ML) techniques in combination with geospatial analysis in southern Brazil.

Methods

Ecological study using secondary and retrospective data on mortality due to ischemic heart disease (IHD) obtained from the Mortality Information Systems (SIM-DATASUS) de 2018 a 2022, covering 1,191 municipalities in the states of Paraná (399), Santa Catarina (295), and Rio Grande do Sul (497). Ordinary Least Squares Regression (OLS), Geographically Weighted Regression (GWR), Random Forest (RF), and Geographically Weighted Random Forest (GWRF) analyses were performed to verify the model with the best performance capable of identifying the most affected sites by the disease based on a set of predictors composed by variables of procedures and access to health.

Results

In the analyzed period, there were 59,093 deaths, 65% of which were men, 82.7% were white, and 72.8% occurred between 60 and 70 years of age. Ischemic heart disease presented the highest mortality rates in the northwest and north regions of the state of Paraná, and in the central-east, southwest and southeast regions of Rio Grande do Sul, the latter state accounting for 41% of total deaths. The GWRF presented the best performance with R2 = 0.983 and AICc = 2298.4, RMSE: 3.494 and the most important variables of the model in descending order were electrocardiograph rate, cardiac catheterization rate, access index to hemodynamics, access index of pre-hospital mobile units, cardiologists rate, myocardial scintigraphy rate, stress test rate, and stress echocardiogram rate.

Conclusion

The GWRF identified spatial heterogeneity in the variation of geographic predictors, contrasting the limitation of linear regression models. The findings showed patterns of vulnerability in southern Brazil, suggesting the formulation of health policies to improve access to diagnostic and therapeutic resources, with the potential to reduce IHD mortality.

Myocardial Infarction Quality of Care and Outcomes in Asian Ethnic Groups in the United States

BACKGROUND

National-level differences in myocardial infarction (MI) quality of care among Asian patients in the United States are unclear. We assessed the quality of MI care in the 6 largest US Asian ethnic groups.

METHODS

Patients aged ≥18 years with ST-segment-elevation MI or non-ST-segment-elevation MI in the Get With The Guidelines-Coronary Artery Disease registry (711 US hospitals, 2015-2021) were assessed. The odds of MI-related quality of care and process outcomes were evaluated in Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and other Asian adults compared with non-Hispanic White adults. Sex-stratified logistic regression models were adjusted for age and clinical characteristics.

RESULTS

There were 5691 Asian patients (1520 Asian Indian, 422 Chinese, 430 Filipino, 114 Japanese, 283 Korean, 553 Vietnamese, and 2369 other Asian) and 141 271 non-Hispanic White patients, overall 30% female, and mean age of 66.5 years. Relative to non-Hispanic White adults, among patients with ST-segment-elevation MI, door-to-ECG time ≤10 minutes was less likely in Asian Indian (adjusted odds ratio [aOR], 0.64 [95% CI, 0.50-0.82]), Chinese (aOR, 0.65 [95% CI, 0.46-0.93]), and Korean (aOR, 0.57 [95% CI, 0.33-0.97]) men and in other Asian women (aOR, 0.61 [95% CI, 0.41-0.90]). Door-to-balloon time ≤90 minutes was less likely in Asian Indian men (aOR, 0.71 [95% CI, 0.56-0.90]) and Filipina women (aOR, 0.48 [95% CI, 0.24-0.98]). In patients with ST-segment-elevation MI or non-ST-segment-elevation MI, optimal medical therapy for MI was less likely in Korean men (aOR, 0.65 [95% CI, 0.47-0.90]) and more likely in Asian Indian men (aOR, 1.22 [95% CI, 1.06-1.40]) and women (aOR, 1.32 [95% CI, 1.04-1.67]) and Filipina women (aOR, 1.84 [95% CI, 1.27-2.67]).

CONCLUSIONS

MI quality of care varies among US Asian patients with ST-segment-elevation MI and non-ST-segment-elevation MI. Quality improvement programs must identify and address the factors that result in suboptimal MI quality of care among US Asian patients.

Empowering Research With the American Heart Association Get With The Guidelines Registries Through Integration of a Database and Research Tools

BACKGROUND

The American Heart Association's Get With The Guidelines (GWTG) has emerged as a vital resource in advancing the standards and practices of inpatient care across stroke, heart failure, coronary artery disease, atrial fibrillation, and resuscitation focus areas. The GWTG registry data have also created new opportunities for secondary use of real-world clinical data in biomedical research. Our goal was to implement a scalable database with an integrated user interface (UI) to improve GWTG data management and accessibility.

METHODS

The curation of registry data begins by going through a data processing and quality control pipeline programmed in Python. This pipeline includes data cleaning and record exclusion, variable derivation and unit harmonization, limited data set preparation, and documentation generation of the registry data. The database was built using PostgreSQL, and integrations between the database and the UI were built using the Django Web Framework in Python. Smaller subsets of data were created using SQLite database files for distribution purposes. Use cases of these tools are provided in the article.

RESULTS

We implemented an automated data curation pipeline, centralized database, and UI application for the American Heart Association GWTG registry data. The database and the UI are accessible through a Precision Medicine Platform workspace. As of March 2024, the database contains over 13.2 million cleaned GWTG patient records. The SQLite subsets benefit researchers by optimizing data extraction and manipulation using Structured Query Language. The UI improves accessibility for nontechnical researchers by presenting data in a user-friendly tabular format with intuitive filtering options.

CONCLUSIONS

With the implementation of the GWTG database and UI application, we addressed data management and accessibility concerns despite its growing scale. We have launched tools to provide streamlined access and accessibility of GWTG registry data to all researchers, regardless of familiarity or experience in coding.

Racial Disparities in Outcomes of Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of ST-segment elevation myocardial infarction (STEMI), predominantly affecting women. Because primary percutaneous coronary intervention (PPCI) is reserved for a select group of patients, vulnerable and minority patients may experience delays in appropriate management and adverse outcomes. We examined the racial differences in the outcomes for patients with SCAD who underwent PPCI for STEMI. Records of patients aged ≥18 years who underwent PPCI for SCAD-related STEMI between 2016 and 2020 were identified from the National Inpatient Sample database. Clinical, socioeconomic, and hospital characteristics were compared between non-White and White patients. Weighted multivariate analysis assessed the association of race with inpatient mortality, length of stay (LOS), and hospitalization costs. The total weighted estimate of patients with SCAD-STEMI who underwent PPCI was 4,945, constituting 25% non-White patients. Non-White patients were younger (56 vs 60.7 years, p <0.001); had a higher prevalence of diabetes, acute renal failure, and obesity; and were more likely to be uninsured and be in the lowest income group. Inpatient mortality (7.7% vs 8.4%, p = 0.74) and hospitalization costs ($34,213 vs $31,858, p = 0.27) were similar for non-White and White patients, and the adjusted analysis did not show any association between the patients' race and inpatient mortality (odds ratio 0.60, 95% confidence interval [CI] 0.32 to 1.13, p = 0.11) or hospitalization costs (β [β coefficient]: 215, 95% CI -4,193 to 4,623, p >0.90). Similarly, there was no association between the patients' race and LOS (incident rate ratio 1.20, 95% CI 1.00 to 1.45, p = 0.054). The weighted multivariate analysis showed that age; clinical co-morbidities such as diabetes, acute renal failure, valvular dysfunction, and obesity; low-income status; and hospitalization in the western region were associated with adverse outcomes. In conclusion, our study does not show any differences in inpatient mortality, LOS, and hospitalization costs between non-White and White patients who underwent PPCI for SCAD-related STEMI.

Relationship between angiogenesis biomarker endocan and apolipoproteins in patients with acute myocardial infarction

Aim: In the current study, serum levels of endocan in patients attended with ST-elevation myocardial infarction, as well as the possible correlation with apolipoprotein-A1 (APO-A1) and APO-B were investigated.Materials & methods: In 80 men, endocan, cTnI, APO-A1, and APO-B levels were measured. Finally, the correlation of endocan with APO-A1, APO-B, and APO-B/ APO-A1 ratio was assessed.Results: Significant changes in APO-A1, APO-B, endocan levels, and APO-B/APO-A1 ratio were found in acute myocardial infarction cases compared with the control arm (p < 0.05). In addition, our finding showed a significant correlation between APO-B and endocan levels, but not APO-A.Conclusion: High endocan level is an independent indicator of endothelial dysfunction and ischemic cardiovascular conditions, which could be related to APO-B.

Prevalence, predictors, and in-hospital outcomes of ST-elevation myocardial infarction among young adults without traditional cardiovascular risk factors in the United States

Background

Standard Modifiable Cardiovascular Risk Factors (SMuRF) such as hypertension, diabetes mellitus, hypercholesterolemia, and smoking have long been established in the etiology of atherosclerotic disease. Studies suggest that patients without any of these risk factors (SMuRF-less) who present with ST-elevation myocardial infarction have worse outcomes.

Methods

The National Inpatient Sample databases (2016 to 2020) was queried to identify STEMI admissions as a principal diagnosis using ICD 10 codes. The study population aged 18 to 45 years were divided into cohorts of SMuRF and SMuRF-less based on the presence of ≥1 risk factor (hypertension, diabetes mellitus, hyperlipidemia, and smoking), and in-hospital outcomes were compared.

Results

41,990 patients were identified as the final study population. 38,495 patients were identified as SMuRF, and 3495 patients were SMuRF-less. Compared to SMuRF patients, SMuRF-less patients are more likely to be females (23.2 % vs. 21.2 %), have congestive heart failure (16.6 % vs. 13.7 %, p < 0.01) but less likely to have obesity (13.7 % vs 28.0 %, p < 0.01) In evaluating outcomes, SMuRF-less patients had higher adjusted in-hospital mortality (aOR 2.6, CI 1.5-4.2, p < 0.01), Cardiogenic shock (aOR 1.8, CI 1.3-2.5, p < 0.01), acute kidney injury (aOR 1.4, CI 1.0-1.9, p = 0.02), and Extramembrane Corporeal Oxygenation (aOR 4.1, CI 1.1-15.1, p = 0.03). Fluid and electrolyte abnormalities was an independent predictor of mortality among SMuRF-less patients (aOR 3.82, CI 1.3-11.2, p < 0.01).

Conclusion

Young patients who present with STEMI and have no traditional cardiovascular risk factors have worse in-hospital outcomes. Further research is needed to evaluate the impact of non-traditional risk factors on acute myocardial infarction.

The COVID-19 impact on STEMI disparities

ST-segment elevation myocardial infarction (STEMI) is a significant source of morbidity and mortality. Despite guideline-driven management and increased awareness of social determinants of health, there are persistent disparities in diagnosis, management, and outcomes. The coronavirus disease 2019 (COVID-19) pandemic has greatly affected emergency department visitation, conditions and throughput. The aim of this study was to find any potential health disparities in patients who presented with STEMI during the COVID-19 pandemic by reviewing STEMI care data from April to September 2019 (pre-pandemic) and April to September 2020 (during the pandemic) for our hospital system. Patients with STEMI within 12 h of presentation were included in this study, and subdivided by age, gender, and race/ethnicity. We compared the turnaround times between emergency department arrival to intervention (electrocardiogram or catheterization) within the patient subgroups to find any notable differences. No statistically significant changes in turnaround times during either study period were found based on age, gender, or race/ethnicity for the STEMI interventions despite shifts in emergency department resources during the pandemic. This study helped assess the status quo in STEMI intervention for our health system and serves as a baseline for us to monitor gaps in care or areas of improvement. As healthcare systems institute new measures to promote equitable care, such as improving the accuracy of demographic data capture, establishing a baseline is an essential first step in evaluating the impact of these measures.