A study from one of the largest public health systems in the country has found that African American patients experienced significantly worse outcomes after angioplasty and stenting than patients of other races, though researchers are not sure why. According to data reported today at the Society for Cardiovascular Angiography and Interventions (SCAI) 32nd Annual Scientific Sessions, no single factor explains why African Americans were at higher risk after percutaneous coronary intervention (PCI), but the hazard was clear.
"We need to be vigilant about evaluating and controlling all risk factors in this vulnerable population of patients," said Sandeep Nathan, MD, an assistant professor of medicine and director of the interventional cardiology fellowship program at the University of Chicago Medical Center. "Despite our best efforts to provide optimal care to all patients, we need to ask, 'What's missing?'"
For the study, Dr. Nathan and his colleagues recruited 1,410 consecutive patients who had a PCI procedure at Cook County Hospital in Chicago. Patients were included in the study only if complete clinical and procedural information was available and follow-up care would be provided through the Cook County public health system. Patients were 57 years old, on average. Some 32% were women and 46% were African American. Patients had PCI for a variety of reasons: stable coronary artery disease in 29.1%, a type of heart attack known as ST-elevation myocardial infarction (STEMI) in 17.1%, a non-STEMI heart attack in 27.9%, and unstable angina in 26.0%.
Patients were grouped according to gender and race and followed-up for an average of 1.7 years. During that time, men and women were equally likely to experience a major adverse cardiac event (MACE), which included heart attack, death, or urgent need for another procedure in the treated coronary artery. However, the likelihood of survival without experiencing any of these cardiac problems was significantly lower in African Americans than in patients of other races (78.8% vs. 85.9%, p<0.001). When researchers took into account factors that might skew the data, such as the reason for PCI, whether the patient was clinically stable or unstable at the time of the procedure, and pre-existing medical conditions, African Americans still showed a trend toward poorer outcomes (p=0.06).
The researchers are continuing to comb through the data for factors that signal an increased risk for African Americans after PCI. In the meantime, there are several possible explanations for these findings based on clinical impressions alone, Dr. Nathan said. One of the most likely is that African American patients appeared to wait longer before coming in for treatment. As a result, they were more likely to have advanced coronary disease that was more complicated to treat with PCI, as well as other medical conditions that worsen PCI outcomes, such as high blood pressure and kidney damage. Another key factor may be a lack of adherence to prescribed medications.
These findings may signal a need for better outreach and education. "As physicians, we need to provide excellent medical care, but also be sensitive to sociocultural issues, problems with access to care, and the importance of building trust between the physician and patient," Dr. Nathan said.