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Factors Associated With Racial Differences in Myocardial Infarction Outcomes
- John A. Spertus, MD, MPH;
- Philip G. Jones, MS;
- Frederick A. Masoudi, MD, MSPH;
- John S. Rumsfeld, MD, PhD; and
- Harlan M. Krumholz, MD, SM*
- From the Mid America Heart Institute of Saint Luke's Hospital and University of Missouri–Kansas City, Kansas City, Missouri; Denver Health Medical Center, University of Colorado at Denver Health Sciences Center, and Denver Veterans Affairs Medical Center, Denver, Colorado; and Yale–New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut.
Abstract
Background: Little information is available about factors associated with racial differences across a broad spectrum of post–myocardial infarction outcomes, including patients' symptoms and quality of life.
Objective: To determine racial differences in mortality, rehospitalization, angina, and quality of life after myocardial infarction and identify the factors associated with these differences.
Design: Prospective cohort study.
Setting: 10 hospitals in the United States.
Patients: 1849 patients who had myocardial infarction, 28% of whom were black.
Measurements: Demographic, economic, clinical, psychosocial, and treatment characteristics and outcomes were prospectively collected. Outcomes included time to 2-year all-cause mortality, 1-year rehospitalization, and Seattle Angina Questionnaire–assessed angina and quality of life.
Results: Black patients had higher unadjusted mortality (19.9% vs. 9.3%; P < 0.001) and rehospitalization rates (45.4% vs. 40.4%; P = 0.130), more angina (28.0% vs. 17.8%; P < 0.001), and worse mean quality of life (80.6 [SD, 22.5] vs. 85.9 [SD, 17.2]; P < 0.001). After adjustment for patient characteristics, black patients trended toward greater mortality (hazard ratio, 1.29 [95% CI, 0.92 to 1.81]; P = 0.142), fewer rehospitalizations (hazard ratio, 0.82 [CI, 0.66 to 1.02]; P = 0.071), and higher likelihood of angina at 1 year (odds ratio, 1.41 [CI, 1.03 to 1.94]; P = 0.032) but similar quality of life (mean difference, −0.6 [CI, −3.4 to 2.2]). Adjustment for site of care further attenuated mortality differences (hazard ratio, 1.04 [CI, 0.71 to 1.52]; P = 0.84). Adjustment for treatments had minimal effect on any association.
Limitation: Residual confounding and missing data may have introduced bias.
Conclusion: Although black patients with myocardial infarction have worse outcomes than white patients, these differences did not persist after adjustment for patient factors and site of care. Further adjustment for treatments received minimally influenced observed differences. Strategies that focus on improving baseline cardiac risk and hospital factors may do more than treatment-focused strategies to attenuate racial differences in myocardial infarction outcomes.
Funding: The National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease, CV Therapeutics, and Cardiovascular Outcomes.
Article and Author Information
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Acknowledgment: The authors thank Peter Austin, PhD.
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Grant Support: By the National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease (grant no. P50 HL077113); CV Therapeutics, Palo Alto, California; and Cardiovascular Outcomes, Kansas City, Missouri.
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Potential Financial Conflicts of Interest: Honoraria: F.A. Masoudi (United Healthcare). Other: J.A. Spertus (copyright holder, Seattle Angina Questionnaire).
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Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Dr. Spertus (Spertusj{at}umkc.edu).
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Requests for Single Reprints: John A. Spertus, MD, MPH, Mid America Heart Institute, 4401 Wornall Road, 5th Floor, Kansas City, MO 64111; e-mail, Spertusj{at}umkc.edu.
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Current Author Addresses: Dr. Spertus and Mr. Jones: Mid America Heart Institute, 4401 Wornall Road, 5th Floor, Kansas City, MO 64111.
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Dr. Masoudi: Colorado Health Outcomes Program, 12477 East 19th Street, Building 406, 2nd Floor West Wing, Aurora, CO 80010.
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Dr. Rumsfeld: Denver Veterans Affairs Medical Center, 1055 Clermont Street, Cardiology, Room 111 B, Denver, CO 80220.
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Dr. Krumholz: 333 Cedar Street, Room IE-61SHM, New Haven, CT 06520.
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Author Contributions: Conception and design: J.A. Spertus, P.G. Jones, J.S. Rumsfeld, H.M. Krumholz.
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Analysis and interpretation of the data: J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.
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Critical revision of the article for important intellectual content: J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.
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Final approval of the article: J.A. Spertus, P.G. Jones, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.
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Provision of study materials or patients: H.M. Krumholz.
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Statistical expertise: P.G. Jones.
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Obtaining of funding: H.M. Krumholz.
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Administrative, technical, or logistic support: H.M. Krumholz.
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Collection and assembly of data: J.A. Spertus, F.A. Masoudi, J.S. Rumsfeld, H.M. Krumholz.
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↵* For a list of members of the Cardiovascular Outcomes Research Consortium who participated in this study, see the Appendix.
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