If African Americans don't fare as well after an acute MI as whites do, as a lot
of evidence shows, it's not so much because of any differences in how they are
treated in the hospital or after discharge--more likely, it's because they
present with more comorbidities and have more cardiovascular risk factors, a
prospective cohort study suggests [1].

In an analysis of 1849 patients with acute MI managed at 10 hospitals across the
US, the 28% who were black developed more angina, had a poorer quality of life
over the following year, and were more likely to die over the next two years,
compared with the 72% who were white. Complicating the picture, however, were
significant baseline differences between the racial groups in socioeconomic and
clinical features as well as medical history.

For example, blacks had more diabetes, chronic renal failure and heart failure,
and hypertension and were more likely to have had a stroke; they also had less
education and health-insurance coverage (p<0.001 in all cases).

After those differences were controlled for, outcomes disparities all but
disappeared. Further adjustment for the treatments blacks and whites received
had little effect on the numbers, observed the authors of the study, led by Dr
John A Spertus (Mid America Heart Institute, Kansas City, MO). Their report
appears in the March 3, 2009 issue of the Annals of Internal Medicine.

Blacks had worse acute-MI outcomes primarily because they were sicker to begin
with and differed from whites in other ways at baseline, so "strategies that
[focus on] more aggressive treatment in the hospital may not be as influential
as primary-prevention efforts in eradicating the disparities," Spertus told
heartwire, "or as [influential as] secondary-prevention efforts that minimize
the burden of comorbid diseases and socioeconomic differences."

The cohort included only black and white patients from the Prospective Registry
Evaluating Myocardial Infarction: Events and Recovery (PREMIER) who survived to
hospital discharge.

Blacks had more than twice the risk of death at two years than did whites, even
after adjustment for demographics and socioeconomic factors. Those significant
differences became nonsignificant only after further adjustment for medical
history and baseline clinical features.

Angina within one year followed a similar pattern, with blacks experiencing
significantly more until socioeconomic factors were considered. Their quality of
life over one year was significantly reduced only until adjustment for
demographics.

"We don't want to minimize the importance of certain treatments that really are
done less often in blacks than whites. I think that's a real problem that we
need to improve," according to Spertus. But addressing those differences
wouldn't be nearly enough to correct observed outcomes disparities, which seem
more related to factors in place before patients get to the hospital, he said.

"We need to think creatively about how to have a healthcare system that can
minimize the racial disparities in the comorbid conditions," Spertus said. "I
think that's not easily done--there are a lot of differences between the overall
health of black and white patients in America. But we have to try to understand
their causes."

The study was funded by the National Heart, Lung, and Blood Institute, CV
Therapeutics, and Cardiovascular Outcomes. Spertus reports holding the copyright
to the Seattle Angina Questionnaire, which was used to evaluate anginal status
in PREMIER. Coauthor Dr Frederick A Masoudi (University of Colorado, Denver)
reports receiving honoraria from United Healthcare.


Spertus JA, Jones PG, Masoudi FA, et al. Factors associated with racial
differences in myocardial infarction outcomes. Ann Intern Med 2009; 150:314-324.