Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study

Ethnic minorities treated with new-generation drug-eluting coronary stents in two European randomised clinical trials

BACKGROUND

Several ethnic minorities have an increased risk of cardiovascular events, but previous European trials that investigated clinical outcome after coronary stenting did not assess the patients' ethnic background.

AIMS

To compare ethnic minority and Western European trial participants in terms of both cardiovascular risk profile and 1‑year clinical outcome after percutaneous coronary intervention.

METHODS

In the BIO-RESORT and BIONYX randomised trials, which assessed new-generation drug-eluting stents, information on patients' self-reported ethnic background was prospectively collected. Pooled patient-level data of 5803 patients, enrolled in the Netherlands and Belgium, were analysed in this prespecified analysis. The main endpoint was target vessel failure after 1 year.

RESULTS

Patients were classified as belonging to an ethnic minority (n = 293, 5%) or of Western European origin (n = 5510, 95%). Follow-up data were available in 5772 of 5803 (99.5%) patients. Ethnic minority patients were younger, less often female, more often current smokers, more often medically treated for diabetes, and more often had a positive family history of coronary artery disease. The main endpoint target vessel failure did not differ between ethnic minority and Western European patients (3.5% vs 4.9%, hazard ratio 0.71, 95% confidence interval 0.38-1.33; p = 0.28). There was also no difference in mortality, myocardial infarction, and repeat revascularisation rates.

CONCLUSIONS

Despite the unfavourable cardiovascular risk profile of ethnic minority patients, short-term clinical outcome after treatment with contemporary drug-eluting stents was highly similar to that in Western European patients. Further efforts should be made to ensure the enrolment of more ethnic minority patients in future coronary stent trials.

Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management

BACKGROUND AND AIMS

A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40).

CONCLUSIONS

This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.

Trends in ST-elevation myocardial infarction hospitalization among young adults: a binational analysis

BACKGROUND

ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients who suffer from STEMI under the age of 50 who are not well characterized in studies.

METHODS AND RESULTS

We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010 and 2017 and the National Inpatient Sample (NIS) from the United States of America (USA) between 2010 and 2018. After exclusion criteria, there were 32 719 STEMI patients aged ≤50 from MINAP, and 238 952 patients' ≤50 from the NIS. We analysed temporal trends in demographics, management, and mortality. The proportion of females increased, 15.6% (2010-2012) to 17.6% (2016-2017) (UK) and 22.8% (2010-2012) to 23.1% (2016-2018) (USA). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (USA). Invasive coronary angiography (ICA) rates increased in UK (2010-2012: 89.0%, 2016-2017: 94.3%), while decreased in USA (2010-2012: 88.9%, 2016-2018: 86.2% (USA). After adjusting for baseline characteristics and management strategies, there was no difference in all-cause mortality in the UK in 2016-2017 compared to 2010-2012 (OR:1.21, 95% CI:0.60-2.40), but there was a decrease in the USA in 2016-2018 compared to 2010-2012 (OR: 0.84, 95% CI: 0.79-0.90).

CONCLUSION

The demographics of young STEMI patients have temporally changed in the UK and USA, with increased proportions of females and ethnic minorities. There was a significant increase in the frequency of diabetes mellitus over the respective time periods in both countries.

Heart Failure Readmission in Patients With ST-Segment Elevation Myocardial Infarction and Active Cancer

Background

Although numerous studies have examined readmission with heart failure (HF) after acute myocardial infarction (AMI), limited data are available on HF readmission in cancer patients post-AMI.

Objectives

This study aimed to assess the rates and factors associated with HF readmission in cancer patients presenting with ST-segment elevation myocardial infarction (STEMI).

Methods

A nationally linked cohort of STEMI patients between January 2005 and March 2019 were obtained from the UK Myocardial Infarction National Audit Project registry and the UK national Hospital Episode Statistics Admitted Patient Care registry. Multivariable Fine-Gray competing risk models were used to evaluate HF readmission at 30 days and 1 year.

Results

A total of 326,551 STEMI indexed admissions were included, with 7,090 (2.2%) patients having active cancer. The cancer group was less likely to be admitted under the care of a cardiologist (74.5% vs 81.9%) and had lower rates of invasive coronary angiography (62.2% vs 72.7%; P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%). There was a significant prescription gap in the administration of post-AMI medications upon discharge such as an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (49.5% vs 71.1%) and beta-blockers (58.4% vs 68.0%) in cancer patients. The cancer group had a higher rate of HF readmission at 30 days (3.2% vs 2.3%) and 1 year (9.4% vs 7.3%). However, after adjustment, cancer was not independently associated with HF readmission at 30 days (subdistribution HR: 1.05; 95% CI: 0.86-1.28) or 1 year (subdistribution HR: 1.03; 95% CI: 0.92-1.16). The opportunity-based quality indicator was associated with higher rates of HF readmission independent of cancer diagnosis.

Conclusions

Cancer patients receive care that differs in important ways from patients without cancer. Greater implementation of evidence-based care may reduce HF readmissions, including in cancer patients.

Socioeconomic disparities in the management and outcomes of acute myocardial infarction

BACKGROUND

Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear.

METHODS

Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and 'ethnic-minority' patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality.

RESULTS

More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001).

CONCLUSION

Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients.

Life expectancy following a cardiovascular event in individuals with and without type 2 diabetes: A UK multi-ethnic population-based observational study

BACKGROUND AND AIMS

We aimed to evaluate the life expectancy following the first cardiovascular disease (CVD) event by type 2 diabetes (T2D) status and ethnicity.

METHODS AND RESULTS

We used the Clinical Practice Research Datalink database in England (UK), linked to the Hospital Episode Statistics information, to identify individuals with and without T2D who survived a first CVD event between 1st Jan 2007 and 31st Dec 2017; subsequent death events were extracted from the Office for National Statistics database. Ethnicity was categorised as White, South Asian (SA), Black, or other. Flexible parametric survival models were used to estimate survival and predict life expectancy. 59,939 individuals with first CVD event were included: 7596 (12.7%) with T2D (60.9% men; mean age at event: 69.7 years [63.2 years in SA, 65.9 in Black, 70.2 in White]) and 52,343 without T2D (56.7% men; 65.9 years [54.7 in Black, 58.2 in SA, 66.3 in White]). Accounting for potential confounders (sex, deprivation, lipid-lowering medication, current smoking, and pre-existing hypertension), comparing individuals with vs without T2D the mortality rate was 53% higher in White (hazard ratio [HR]: 1.53 [95% CI: 1.44, 1.62]), corresponding to a potential loss of 3.87 (3.30, 4.44) life years at the age of 50 years in individuals with T2D. No evidence of a difference in life expectancy was observed in individuals of SA (HR: 0.82 [0.52, 1.29]; -1.36 [-4.58, 1.86] life years), Black (HR: 1.26 [0.59, 2.70]; 1.21 [-2.99, 5.41] life years); and other (HR: 1.64 [0.80, 3.39]; 3.89 [-2.28, 9.99] life years) ethnic group.

CONCLUSION

Following a CVD event, T2D is associated with a different prognosis and life years lost among ethnic groups.

Distribution of lipid levels and prevalence of hyperlipidemia: data from the NHANES 2007-2018

Background

Lipid-lowering therapy is important, and the distribution of lipid levels and the incidence of hyperlipidemia may vary in different subgroups of the population. We aimed to explore the distribution of lipid levels and the prevalence of hyperlipidemia in subpopulations with subgroup factors, including age, sex, race, and smoking status.

Methods

Our study used data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018, ultimately enrolling and analyzing 15,499 participants. A cross-sectional analysis was performed to assess the distribution of lipids and prevalence of hyperlipidemia in subpopulations, and multifactorial logistic regression analyses were performed for the prevalence of hyperlipidemia, adjusted for age, sex, race and smoking status.

Results

Blacks had significantly lower mean serum total cholesterol and triglycerides and higher serum high-density lipoprotein cholesterol (HDL-C) than whites (P < 0.001). In contrast, Mexican Americans had markedly higher mean serum triglycerides and lower serum HDL-C than whites (P < 0.001). Furthermore, the prevalence of hypercholesterolemia and hypertriglyceridemia was lower in blacks than in whites (P = 0.003 and P < 0.001, respectively), while the prevalence of hypertriglyceridemia was significantly higher in Mexican Americans than in whites (P = 0.002). In addition, total cholesterol and triglyceride levels were significantly higher in women aged 65 years or older and markedly higher than in men in the same age group (P < 0.001). In addition, overall mean total cholesterol, triglyceride, and low-density lipoprotein cholesterol (LDL-C) levels were higher in smokers than in nonsmokers (P = 0.01, P < 0.001, and P = 0.005, respectively).

Conclusion

Based on NHANES data, the mean lipid levels and prevalence of hyperlipidemia differed by sex, age, race, and smoking status.

Mortality in ST-segment elevation myocardial infarction patients without standard modifiable risk factors: A race disaggregated analysis

Background

Individuals who present with STEMI without the standard cardiovascular risk factors (SMuRFs) of diabetes, hypercholesterolemia, hypertension, and smoking, coined SMuRF-less are not uncommon. Little is known about their outcomes as a cohort and how they differ by race.

Methods & Results

We identified 431,615 admissions with STEMI in the National Inpatient Sample (NIS) database 2015–2018, including patients with ≥ 1 SMuRF (n = 369,870) and those who were SMuRF-less (n = 234,745). SMuRF-less patients presented at a similar age (median age 63y vs 63y), were less likely to be female (33.6 % vs 34.6 %) and were almost twice as likely to present as a cardiac arrest (13.7 % vs 7.0 %), than those with ≥ 1 SMuRFs. SMuRF-less patients were less frequently in receipt of ICA (71.3 % vs 83.8 %) and PCI (58.0 % vs 72.2 %) compared to those with ≥ 1 SMuRF. Our race disaggregated analysis showed ethnic minority SMuRF-less patients were less likely than White patients to receive ICA and PCI, which was most apparent in Black patients with reduced odds of ICA (OR: 0.47, 95 % CI: 0.43–0.52) and PCI (OR: 0.46, 95 % CI: 0.52–0.50). Similarly, in ethnic minority subgroups within the SMuRF-less cohort, mortality and MACCE were significantly higher than in White patients. This was most profound in Black patients with in-hospital mortality (OR: 1.90, 95 % CI: 1.72–2.09) and MACCE (OR: 1.63, 95 % CI: 1.49–1.78) compared to White patients.

Conclusion

Ethnic Minority SMuRF-less patients were less likely than White SMuRF-less patients to receive ICA and PCI and had worse mortality outcomes.

Impact of the admitting ward on care quality and outcomes in non-ST-segment elevation myocardial infarction: insights from a national registry

AIMS

Little is known about the association between the type of admission ward and quality of care and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS AND RESULTS

We analysed data from 337 155 NSTEMI admissions between 2010 and 2017 in the UK Myocardial Ischaemia National Audit Project (MINAP) database. The cohort was dichotomised according to receipt of care either on a medical (n = 142,876) or cardiac ward, inclusive of acute cardiac wards and cardiac care unit (n = 194,279) on admission to hospital. Patients admitted to a cardiac ward were younger (median age 70 y vs. 75 y, P < 0.001), and less likely to be female (33% vs. 40%, P < 0.001). Independent factors associated with admission to a cardiac ward included ischaemic ECG changes (OR: 1.20, 95% CI: 1.18-1.23) and prior percutaneous coronary intervention (PCI) (OR: 1.19, 95% CI: 1.16-1.22). Patients admitted to a cardiac ward were more likely to receive optimal pharmacotherapy with statin (85% vs. 81%, P < 0.001) and dual antiplatelet therapy (DAPT) (91% vs. 88%, P < 0.001) on discharge, undergo invasive coronary angiography (78% vs. 59%, P < 0.001), and receive revascularisation in the form of PCI (52% vs. 36%, P < 0.001). Following multivariable logistic regression, the odds of inhospital all-cause mortality (OR: 0.75, 95% CI: 0.70-0.81) and major adverse cardiovascular events (MACE) (OR: 0.84, 95% CI: 0.78-0.91) were lower in patients admitted to a cardiac ward.

CONCLUSION

Patients with NSTEMI admitted to a cardiac ward on admission were more likely to receive guideline directed management and had better clinical outcomes.

Interaction Between Race, Ethnicity, Severe Mental Illness, and Cardiovascular Disease

Severe mental illnesses, such as schizophrenia or bipolar disorder, affect ≈1% of the population who, as a group, experience significant disadvantage in terms of physical health and reduced life expectancy. In this review, we explore the interaction between race, ethnicity, severe mental illness, and cardiovascular disease, with a focus on cardiovascular care pathways. Finally, we discuss strategies to investigate and address disparities in cardiovascular care for patients with severe mental illness.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales

BACKGROUND

Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown.

METHODS

Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy.

RESULTS

From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group.

CONCLUSIONS

BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study

AIMS

The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes.

METHODS AND RESULTS

We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P < 0.001), male (62% vs. 61%, P < 0.001), and Caucasian (95% vs. 92%, P < 0.001). Those without SMuRFs less frequently received statins (71% vs. 81%, P < 0.001), had their left ventricular (LV) function recorded (62% vs. 65%, P < 0.001) or for those with moderate or severe LV systolic dysfunction were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (80% vs. 85%, P < 0.001). Following propensity score matching the odds of all-cause mortality [odds ratio (OR): 0.85, 95% confidence interval (CI): 0.77-0.93], cardiac mortality (OR: 0.85, 95% CI: 0.76-0.94), and major adverse cardiovascular events (MACE) (OR: 0.85, 95% CI: 0.77-0.93) were lower in patients without SMuRFs.

CONCLUSION

More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.