Abstract
Background:
Racial disparities in coronary revascularization have been documented. However, it is unclear whether these disparities are consistent on a national basis among post-menopausal women hospitalized with STEMI and NSTEMI or for chronic stable angina. Our objective was to assess racial and potential SES disparities in emergent treatment of STEMI, revascularization of STEMI, NSTEMI and for any indication among white, blacks and Hispanic post-menopausal women.
Methods:
We used data from the 133,760 post-menopausal women, 11,843 were African-American, 4,875 Hispanic, and 117,042 Caucasian. We compared rates of emergent therapy and of coronary revascularization by race and SES. Emergent therapy is defined as thrombolysis, PCI or CABG within 12 hours of chest pain. PCI and CABG any time during a hospitalization were determined by trained physician adjudicators of hospitalized medical records triggered by participant annual self-report. Low SES was defined as less than a high school education or a household income of less than $20,000. Age-adjusted proportional hazards models were performed to evaluate potential disparities in outcomes. No additional covariate adjustment was performed as established CHD risk factors, insurance status, geography are potential causal mediators of the disparities evaluated.
Results:
Overall, Black women (HR=0.75, 95% CI 0.68-0.82) and Hispanic women (HR=0.69, 95% CI 0.60-0.80) received less revascularization regardless of indication. Black women received less revascularization during a MI hospitalization (HR=0.74, 95% CI 0.62-0.89). For STEMI, Black women received less emergent therapy (HR=0.61, 95% CI 0.48-0.79), less non-emergent revascularization (HR=0.53, 95% CI 0.33-0.86) and overall less revascularization regardless of timing (HR=0.54, 95% CI 0.39-0.75). The number of events in Hispanics precluded analysis. For NSTEMI, no difference by race was found (HR= 0.88, 95%CI 0.70-1.10). Overall, women with low SES received more revascularization (HR=1.40, 95% CI 1.32-1.48) regardless of indication. For STEMI, low SES women compared to high SES received more emergent therapy (HR=1.19, 95% CI 1.03-1.39), and a trend towards more non-emergent revascularization (HR=1.11, 95% CI 0.86-1.44) and revascularization regardless of timing (HR=1.14, 95% CI 0.96-1.37). For NSTEMI, low SES women received more revascularization (HR=1.21, 95% CI 1.04-1.41) than high SES women.
Conclusions:
There appear to be health disparities with regards to race in emergent therapy for STEMI and revascularization for STEMI, MI and any indication in post-menopausal women. We observed an inverse association between revascularization rates and SES suggesting that other factors may need to be considered to explain this relationship. Mediation analyses to better understand the causal factors associated with our findings need to be explored.