Thursday, March 31, 2005

CRUSADE: Treatment Differences Between White and Black Heart Attack Patients
By Julie McKeel

According to a recent study published in the American Heart Association journal Circulation, black heart attack patients are less likely than whites to receive many of the newer, more costly evidence-based treatments for non–ST-segment elevation acute coronary syndromes (NSTE ACS). Though black patients received these evidence-based treatments less often, they had similar or better outcomes.

The researchers, including the DCRI’s Dr. Matthew Roe and Dr. Eric Peterson, used data from 400 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative.

Though numerous advances have been made in recent years in the treatment of patients with ACS, the death rate for patients with non–ST-segment elevation (NSTE) ACS is higher than for those with ST-segment elevation myocardial infarction (MI). The American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction (NSTEMI) were developed to encourage healthcare professionals to make evidence-based decisions when caring for patients with NSTE ACS. Despite continued education efforts, however, large gaps exist between guideline recommendations and the actual treatment of patients with NSTE ACS.

In this latest study, the researchers identified black and white patients (adjusted for demographics and other existing medical conditions) with high-risk NSTE ACS. They compared patient and hospital factors, rates of invasive and noninvasive treatments, and the clinical outcomes in these patients. The treatments were compared against those therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS.

The study included 37,813 (87.3%) white and 5504 (12.7%) black patients. In general, the black patients were younger and more often female. They were more likely to have hypertension, diabetes, heart failure, and kidney dysfunction and less likely to have insurance coverage or primary cardiology care. The nationally representative study sample includes a variety of hospital types (community, academic, Veterans Affairs). The researches used direct chart data rather than relying on administrative data. In addition, this study focused on the broader population with NSTE ACS, the most common type of ACS.

According to the study, more of the black patients received older ACS treatments such as aspirin, beta-blockers, or ACE inhibitors (antihypertensive drugs). They were much less likely to receive newer ACS therapies, including platelet glycoprotein IIb/IIIa inhibitors and clopidogrel, an anticlotting medication used to prevent strokes and heart attacks. In addition, black patients were less likely to receive cardiac catheterization, revascularization procedures, lipid-lowering drugs, or smoking cessation counseling.

The study authors indicate that the patient’s age, race, sex, geographic location, marital status, socioeconomic status, medical insurance status, and existing disease conditions may be related to the lower rate of evidence-based treatment strategies in patients with heart disease. Other studies confirm that black patients with acute MI are less likely than white patients to receive invasive coronary treatments.

The study results show that black patients were significantly less likely than white patients to undergo diagnostic cardiac catheterization or other percutaneous coronary intervention (PCI) options while hospitalized. These treatment differences existed regardless of the patients’ risk of adverse cardiac events. High-risk black patients were also much less likely to undergo coronary artery bypass surgery compared with high-risk white patients.

The researchers admit that their study results are mixed. The use of certain well-established ACS therapies (such as aspirin, beta-blockers, and ACE inhibitors) in blacks was equal to or greater than that seen in whites, but the use of newer or more costly treatments tended to be lower among black patients. The study concluded that black patients with NSTE ACS are less likely than whites to receive invasive treatment options and some medical treatments. While there were no major differences in the use of lower-cost medications, blacks were much less likely to receive recommended, more expensive medications.

The researchers assert that efforts to reduce the differences in treatments administered to black patients should focus on evaluating the role of newer evidence-based therapies in black patients. In addition, educating providers about the cultural sensitivities of their patients and improving patients’ understanding of their disease process would help reduce the disparities in care, regardless of the patient’s ethnic origin. Clinical guidelines should be updated frequently, and education programs implemented to increase the use of guideline recommendations in clinical practice, resulting in improved care for all patients.

CRUSADE is funded by Millennium Pharmaceuticals, Inc, Cambridge, Mass, and Schering Corp, Kenilworth, NJ, comarketers of the most commonly used platelet glycoprotein IIb/IIIa inhibitor. BMS/Sanofi provides an unrestricted grant in support of the program.