Race and Sex Differences in Management and Outcomes of Patients After ST-Elevation and Non-ST-Elevation Myocardial Infarct: Results From the NCDR

Abstract

Background: Race and sex have been shown to affect management of myocardial infarction (MI); however, it is unclear if such disparities exist in contemporary care of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).

Hypothesis: Disparities in care will be less prevalent in more heavily protocol-driven management of STEMI than the less algorithmic care of NSTEMI.

Methods: Data were collected from the ACTION Registry-GWTG database to assess care differences related to race and sex of patients presenting with NSTEMI or STEMI. For key treatments and outcomes, adjustments were made including patient demographics, baseline comorbidities, and markers of socioeconomic status.

Results: Key demographic variables demonstrate significant differences in baseline comorbidities; black patients had higher incidences of hypertension and diabetes, and women more frequently had diabetes. With few exceptions, rates of acute and discharge medical therapy were similar by race in any sex category in both STEMI and NSTEMI populations. Rates of catheterization were similar by race for STEMI but not for NSTEMI, where both black men and women had lower rates of invasive therapy. Rates of revascularization were significantly lower for black patients in both the STEMI and NSTEMI groups regardless of sex. Rates of adverse events differed by sex, with disparities for death and major bleeding; after adjustment, rates were similar by race within sex comparisons.

Conclusions: In this contemporary cohort, although there are differences by race in presentation and management of MI, heavily protocol-driven processes seem to show fewer racial disparities.

Keywords: Acute coronary syndrome; Disparities in Care; Gender; NSTEMI; Race; STEMI.

Figure 1

A (men) and B (women): Odds ratios for black vs white patients to undergo procedure by sex and type of MI. Overall, black patients are significantly less likely to undergo catheterization or revascularization. In the NSTEMI population, all such differences are statistically significant. Abbreviations: CABG, coronary artery bypass grafting; cath, catheterization; CI, confidence interval; MI, myocardial infarction; NSTEMI, non–ST‐segment elevation myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention; STEMI, ST‐segment elevation myocardial infarction.

Figure 2

A (men) and B (women): Odds ratios for black vs white patients presenting with NSTEMI to undergo procedure by race. Data stratified by ACTION risk score into high‐, intermediate‐, and low‐risk groups. The high‐risk group demonstrated few disparities compared with the low‐ and intermediate‐risk groups. Abbreviations: ACTION, Acute Coronary Treatment and Intervention Outcomes Network; CABG, coronary artery bypass grafting; cath, catheterization; CI, confidence interval; int, intermediate; NSTEMI, non–ST‐segment elevation myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention; revasc, revascularization.