Race, Income Remain Predictors of Acute MI Revascularization in Women

Despite better awareness and focused initiatives, Black race and lower income are still associated with a lower likelihood of receiving coronary revascularization among postmenopausal women presenting with acute MI, according to an analysis of the Women’s Health Initiative study.

The data demonstrate long-identified problems, senior author Khadijah Breathett, MD (University of Arizona, Tucson), told TCTMD. “We all know women are less likely to receive appropriate care for cardiovascular treatment, and this shows that it's that much worse for Black women or for women with lower income,” she said.

But given the recent “increased awareness” of these issues and the drive to eliminate health disparities by various policies and programs, this study was designed to see if these efforts have made any difference, said lead author Tarryn Tertulien, MD (University of Pittsburgh Medical Center, PA).

The results, published online last week ahead of print in the American Heart Journal, show in a population of more than 5,200 people presenting with acute MI over several decades that Black versus white patients were less likely to receive coronary revascularization (adjusted HR 0.79; 95% CI 0.66-0.95), as were those with annual incomes under versus over $20,000 (adjusted HR 0.90; 95% CI 0.82-0.99).

While the size of the observed disparities surprised her, Tertulien said, “it’s a slow process in terms of really improving, for example, risk factors such as access to care [and] physical activity. . . . I think it might take a bit longer to see differences.” Further, the data don’t suggest that public health initiatives like Healthy People 2010 did not have an overall impact, she added.

Commenting on the results for TCTMD, Erin D. Michos, MD (Johns Hopkins University School of Medicine, Baltimore, MD), said it was “disheartening” to see that racial disparities in revascularization access for acute MI have not improved over time. “I would have thought that maybe things would have been better in the more recent era,” she said in an email.

“Race is a social construct rather than a genetic/biologic construct,” Michos continued. “These persistent racial disparities across trials are likely due to social inequities, reduced access to care, and other disparate treatment that can stem from systemic racism. This is really unacceptable and needs to change immediately.”

Disparities Persist

For the analysis, Tertulien and colleagues included data from the Women’s Health Initiative on 5,284 postmenopausal women (mean age 66.3 years; 9.5% Black, 2.8% Hispanic, 87.7% white; 23.2% with annual incomes < $20,000) presenting with acute MI between 1993 and 2019.

We all know women are less likely to receive appropriate care for cardiovascular treatment, and this shows that it's that much worse for Black women or for women with lower income. Khadijah Breathett

While the prevalence of coronary heart disease was similar across racial, ethnic, and income groups, Black women and women with lower incomes had higher proportions of diabetes and hypertension and less physical activity than white women and those with higher incomes. Heart failure was also more prevalent among Black women.

After adjustment, coronary revascularization was less often performed in Black versus white patients but was similarly offered to Hispanic and white women (adjusted HR 1.07; 95% CI 0.82-1.38).

Specifically, Black women were less likely to receive PCI compared with white women (adjusted HR 0.72; 95% CI 0.59-0.90) but similarly offered CABG irrespective of STEMI or NSTEMI presentation. There was no difference in receipt of revascularization type by income.

The researchers noted a steady increase in revascularization between 2005 and 2019 overall, but the racial disparities remained. In fact, in subanalyses looking at before and after 2010, there were still significant racial differences in coronary revascularization.

Standardization, Antiracist Trainings Needed

Tertulien said she hopes these data will increase the importance of recognizing how social determinants of health can affect care for patients with acute MI. She called for more-inclusive studies to address these issues as well as structural racism.

Additionally, Breathett said more standardization “will really start to go a long way.” While the recently updated chest pain and revascularization guidelines “may play a large role,” the entire process of care for these patients needs more standardization, she said. “It can't be based upon the patient’s race or income. Oftentimes misjudgment of adherence levels and ability to return for follow-up should not impact [decisions] about the patient's care. It should be focused on how to address the issues that are contributing to the initial disease presentation.”

This is really unacceptable and needs to change immediately. Erin D. Michos

Michos agreed. “We have established guidelines, but the implementation piece is often lacking,” she said. “We need more implementation science to understand best strategies of how to deliver appropriate guideline-recommended therapies, which include revascularization for acute MI as well as preventive medications such as statins.”

Moreover, Breathett said antiracist and evidence-based bias reduction training should be mandatory for entire institutions and policies should be assessed for their impact on patients based on race, ethnicity, sex, and age. “We know this is a problem across cardiovascular care with the differences in who receives guideline-directed treatment, but it has to be a standard that hospitals have to be willing to step up to,” she said. “And we also must charge the insurance companies to prevent the barriers for allowing the patients to get the medications and the treatment that they need. So it's a major systemic problem that requires a systemic solution.”

Even so, Breathett said she anticipates that change is coming. “Leaders are starting to listen, Institutions care about what's happening to our patients, and I hope that [due to] continued pressure to recognize that we cannot afford to allow for these disparities to persist that change will start to come and equity will become a true priority,” she said.