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Guidelines prescribe universal recommendations for the early invasive treatment of acute coronary syndrome (ACS). However, differential outcomes of ACS by race in the modern era of drug-eluting stents (DES) are not well understood.
We analyzed 835,070 hospitalizations for ACS from the Healthcare Cost and Utilization Project across all insurance types from 2008-2011, examining whether quality of care and outcomes for patients with ACS differed by race (White, Black, Hispanic, Asian, Native American, Other) with adjustment for patient characteristics and clustering by hospital.
We found that black patients were less likely to present with a ST-elevation myocardial infarction (STEMI) compared to other races (23.1% versus 29.1-32.5% for other races, p<0.0001), with Asians and Whites most likely to present with a STEMI. Black patients were also less likely to receive an angiogram within 24 hours of a STEMI (67.6% versus 68.8%-72.2% for other races, p<0.0001) or within 48 hours of a Non-STEMI (44.4% versus 48.7%-50.9% for other races, p<0.0001). Black race was associated with lower use of a DES (29.8% versus 37.8%-39.8% for other races, p<0.0001) and lower use of coronary artery bypass surgery (5.3% versus 8.6%-9.5%, p<0.0001). However, black patients had lower mortality rates (5.2% versus 5.7-7.3% for other races, p<0.0001), despite higher comorbidities. Asian patients had the highest mortality rates (7.31% versus 5.2%-6.7% for other races, p<0.0001), despite rapid times to percutaneous coronary intervention in STEMI (68.8% received angiogram within 24h of STEMI) and NSTEMI (49.5% received angiogram within 24h of STEMI), and the highest use of DES (73.7% versus 63.3%-68.0% for other races, p<0.0001).
Asian patients appeared to have the worst mortality outcomes after ACS, despite high use of early invasive treatments. Black patients have better outcomes despite receiving less guideline-driven treatment for ACS. Further studies, including disaggregation, will be required to discern what factors explain the poor outcomes observed for Asians and to minimize inequities in the invasive treatment of ACS.
OTHER: Quality, Guidelines and Appropriateness Criteria