Cocaine History? For Black Patients It Means Less Chance of Revascularization

ATLANTA, GA—Black patients with ACS and a history of cocaine use are less likely to receive diagnostic angiography or revascularization than white patients with a similar drug history, new research shows.

“The study adds to the growing body of literature that Black patients in the US, in general, have disparities in the care that they receive,” Michael Dangl, MD (University of Miami/Jackson Memorial Hospital, FL), told TCTMD. The data were presented in a poster session here last week at the Society for Cardiovascular Angiography and Interventions 2022 Scientific Sessions. Dangl explained that his Miami hospital frequently sees patients with a history of using cocaine or other drugs. The study grew out of observations that the allocation of patients with non-STEMI and cocaine use to the cath lab was often “somewhat random” if the patient was nonwhite.

When they looked at nationwide US data, they found a similar trend that stretched far beyond Miami. After multivariable logistic regression analysis to control for differences in age, gender, and comorbidities, non-Hispanic Black individuals had a lower odds of cardiac catheterization (adjusted OR 0.77; 95% CI 0.73-0.80) and revascularization with either PCI or CABG (adjusted OR 0.68; 95% CI 0.64-0.71) compared with white individuals.

“A main concern is always will the patient be compliant with antiplatelet therapy, but that is where we believe this subjective evaluation can occur. . . . It leaves room open for biases where providers may decide that a Black patient with a history of cocaine use is less likely than a white patient to be compliant,” Dangl added.

Bias Training May Help

Dangl and colleagues looked at data spanning 2011 and 2019 from the National Inpatient Sample database on 16,893 white patients and 26,905 Black patients with a history of cocaine use and ACS. Compared with white patients, Black patients were more often female, low-income, hypertensive, and diabetic, with higher rates of chronic kidney disease and heart failure.

Cardiac catheterization occurred in 61.7% of Black patients versus 72.5% of white patients and revascularization in 38.4% of Black patients versus 52.1% of white patients (P < 0.001 for both).

“One thing that needs to happen is more implicit bias training [to] be aware of how to look for more-objective measures of a patient’s likelihood of compliance to treatment other than simply making a subjective evaluation of how compliant you think they’ll be,” Dangl said. If a patient is taking medications for other conditions regularly, for example, that can be seen as a sign of willingness to comply with post-PCI medications.

Also noteworthy, Dangl said, is that known treatment disparities could end up causing patients and families to be less forthcoming about a drug history.

“It's always important for patients to be truthful. But, if they realize that they're less likely to be revascularized and that there is stigma or judgment attached to the information they share with providers and that they're not going to receive the same level of care, that certainly might influence their decision about what information they share with their providers,” he added.

The analysis also looked at other substance abuse, including alcohol, tobacco, and methamphetamines.

“The white patients had higher rates of all of them,” Dangl told TCTMD. “So, even with higher rates of other substance abuse, they were still more likely than Black patients to receive revascularization.” He added that he and his colleagues hope the study raises awareness among clinicians to not be so quick in their judgment that they close the door to treatment options that could benefit these patients.