Circulation. 2005;111:1225-1232.

Background

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

Objective

To examine the association of race with guideline-recommended patient management strategies in patients with NSTE ACS.

Methods

Using data from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) registry, black and white patients with high-risk NSTE ACS were identified. The ACC/AHA recommended therapies, and outcomes by race were compared after adjustment for demographics and medical comorbidity.

Results

37,813 (87.3%) white and 5504 (12.7%) black patients were included in the study. Black patients had a similar or higher likelihood than whites of receiving aspirin, beta blockers, or ACE inhibitors, but were significantly less likely to receive newer recommended 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 short-term risk adjusted outcomes were similar between the two groups.

Conclusion

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

Comments

Equality of healthcare delivery is one of the principal tenets of our profession; however, healthcare disparities have been shown to be pervasive and associated with adverse events. Continued efforts should focus on strategies designed to eliminate these disparities, particularly creative ones that involve community-based organizations of the minority cohorts affected. In this study, black and white patients with NSTE ACS were equally likely to receive counseling for dietary modification and being referred for cardiac rehabilitation. A closer look at these data however, show that the rate for dietary counseling was 71% and that the overall referral rate for cardiac rehabilitation was a dismal 41%. Even if one argues that some patients may not be candidates for cardiac rehabilitation, this number still seems quite low. Dietary counseling should reach near 100% in this clinical setting. Hence, this study also underscores the general failure of our current systems of care to deliver evidence-based recommendations for secondary prevention of coronary heart disease.-ST