Racial, Ethnic, and Sex Disparities in Cardiogenic Shock Due to STEMI: ACT NOW!

Race, Ethnicity, and Gender Disparities in Acute Myocardial Infarction

Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care.

The Price We Pay for Progression in Shock Care: Economic Burden, Accessibility, and Adoption of Shock-Teams and Mechanical Circulatory Support Devices

PURPOSE OF REVIEW

Cardiogenic shock (CS) is associated with high in-hospital and long-term mortality and morbidity that results in significant socio-economic impact. Due to the high costs associated with CS care, it is important to define the short- and long-term burden of this disease state on resources and review strategies to mitigate these.

RECENT FINDINGS

In recent times, the focus on CS continues to be on improving short-term outcomes, but there has been increasing emphasis on the long-term morbidity. In this review we discuss the long-term outcomes of CS and the role of hospital-level and system-level disparities in perpetuating this. We discuss mitigation strategies including developing evidence-based protocols and systems of care, improvement in risk stratification and evaluation of futility of care, all of which address the economic burden of CS. CS continues to remain the pre-eminent challenge in acute cardiovascular care, and a combination of multi-pronged strategies are needed to improve outcomes in this population.

Racial and ethnic disparities in the management and outcomes of cardiogenic shock complicating acute myocardial infarction

BACKGROUND

It remains unclear if there remain racial/ethnic differences in the management and in-hospital outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in contemporary practice.

METHODS

We used the National inpatient Sample (2012-2017) to identify a cohort of adult AMI-CS hospitalizations. Race was classified as White, Black and Others (Hispanic, Asian/Pacific Islander, Native Americans). Primary outcome of interest was in-hospital mortality, and secondary outcomes included use of invasive cardiac procedures, length of hospital stay and discharge disposition.

RESULTS

Among 203,905 AMI-CS admissions, 70.4% were White, 8.1% were Black and 15.7% belonged to Other races. Black AMI-CS admissions were more often female, with lower socio-economic status, greater comorbidity, and higher rates of non-ST-segment-elevation AMI-CS, cardiac arrest, and multi-organ failure. Compared to White AMI-CS admissions, Black and Other races had lower rates of coronary angiography (75.3% vs 69.3% vs 73.6%), percutaneous coronary intervention (52.7% vs 48.6% vs 54.8%), and mechanical circulatory devices (48.3% vs 42.8% vs 43.7%) (all p < 0.001). Unadjusted in-hospital mortality was comparable between White (33.3%) and Black (33.8%) admissions, but lower for other races (32.1%). Adjusted analysis with White race as the reference identified lower in-hospital mortality for Black (odds ratio [OR] 0.85 [95% confidence interval {CI} 0.82-0.88]; p < 0.001) and Other races (OR 0.97 [95% CI 0.94-1.00]; p = 0.02). Admissions of Black race had longer hospital stay, and less frequent discharges to home.

CONCLUSIONS

Contrary to previous studies, we identified Black and Other race AMI-CS admissions had lower in-hospital mortality despite lower rates of cardiac procedures when compared to White admissions.