STEMI Plus Shock: Web of Factors Drive Unequal Care and Outcomes

For patients with STEMI complicated by cardiogenic shock, stark racial/ethnic and sex disparities exist in both the treatments they receive and the outcomes achieved, observational US data show.

Prior studies have documented these patterns in patients with STEMI. Cardiogenic shock, known for its “heterogeneity of care,” adds another layer of complexity, researchers note in JACC: Cardiovascular Interventions.

These patients, said lead author Lina Ya’qoub, MD (Ochsner-Louisiana State University, Shreveport), are “really the sickest of all.” Yet the differences don’t come as a surprise, she told TCTMD. They stem from a complex web of socioeconomic factors, insurance status, access to care, social determinants of health, and other disparities on top of what happens—or what doesn’t—at the time of the acute event.

As such, addressing them will take a coordinated effort among primary care physicians, general cardiologists, and interventionalists. “Protocols will definitely help” avoid variations in treatment, said Ya’qoub. What’s needed, she continued, are strong recommendations that specify: “Okay, these patients, when they come in, this is what you do. Everyone should be familiar with it. Nurses, techs, everyone [knows] that’s the protocol no matter how the patient looks or what their background is.”

At the Cleveland Clinic, for example, a protocol designed to improve STEMI care processes also mitigated sex disparities. Data from the CULPRIT-SHOCK trial also have shown that with equal treatment, there’s no gap in outcomes between men and women with acute MI complicated by cardiogenic shock (AMICS).

Saraschandra Vallabhajosyula, MD (Emory University School of Medicine, Atlanta, GA), who didn’t take part in the current study, has done other research illuminating sex disparities in AMICS, including a study focused on younger patients that he conducted with Ya’qoub.

Valuably, this latest analysis shows that the burdens posed by “race, sex, age, socioeconomic status, [and] insurance status are all additive,” he commented to TCTMD. “They all are interrelated, and they all add an extra degree of disparity or additional layer of complexity, which often results in poorer care or less frequent use of guideline-directed measures, and so on and so forth. So these are related and unfortunately negatively related.”

Less-Intensive Care, Worse Outcomes

Ya’qoub et al pulled numbers from the National Inpatient Sample (NIS) from January 2006 to September 2015, identifying 159,339 patients (36.3% women) who had both STEMI and cardiogenic shock. Of the women, 77.9% were white, 8.6% were Black, and 6.8% were Hispanic. Of men, 76.4% were white, 6.2% were Black, and 8.3% were Hispanic. The remaining study participants were described in the NIS records as “other.”

Women tended to be older than men (69.8 vs 63.2 years; P < 0.001) and were more likely to have hypertension, diabetes mellitus, and obesity. Men, on the other hand, were more apt to have hyperlipidemia and chronic obstructive lung disease, as well as to smoke and abuse alcohol. Prior PCI and known CAD were less common in female versus male patients.

No matter their race/ethnicity, women also received less-intensive care than did men, with lower rates of revascularization, right heart catherization, and mechanical circulatory support. There also were nuances by race/ethnicity. For instance, PCI was performed in 62.9% of white women versus 67.0% of white men. Rates were 59.4% versus 66.4%, respectively, in Black patients, and 58.5% versus 66.9% in Hispanic patients.

Complication rates varied, too. Women, for instance, were less likely to experience acute kidney injury compared with men but more likely to have a stroke. Major bleeding was most common in Black men. Women, especially white women, were more likely to receive palliative care consultation. Excluding patients who died, women had lower hospital costs and shorter lengths of stay.

In-hospital mortality was higher among women, ranging from 40.0% in Black patients to 45.4% in Hispanic patients. For men, death rates ranged from 30.4% in “other” patients to 34.7% in Hispanic patients. Adjusted for age, Charlson comorbidity index, hospital bed size, teaching status, and insurance, women as a whole had a higher risk of death compared with white men (OR 1.11; 95% CI 1.06-1.16), as did Black men (OR 1.18; 95% CI 1.04-1.34) and Hispanic men (OR 1.19; 95% CI 1.06-1.33). The highest risk was seen in Hispanic women (OR 1.46; 95% CI 1.26-1.70).

No Simple Fix

Christian Spaulding, MD, PhD (European Hospital Georges Pompidou, University of Paris, France), writing in an editorial, agrees that protocols could be helpful, especially in areas like STEMI with cardiogenic shock “where there is a lack of randomized data and where decisions can be influenced by suppositions and emotions.” But protocols, he says, are not enough.

“Unfortunately, the causes of racial, ethnic, and sex disparities in healthcare are complex and multifactorial, and protocols will not be the only answer,” he cautions. “Trials should include adequately powered predefined subgroup analysis based on sex and race to better understand differences in outcomes. Patient education should take into account cultural backgrounds and linguistic difficulties.”

Spaulding cites the American Hospital Association’s #123forEquity Campaign to Eliminate Health Care Disparities as an “important step forward” in these efforts.

Most crucial of all is access to healthcare, he stresses. “In Europe, most countries have health systems with universal and lifelong state or regional insurances that cover the entire cost of emergent and/or major procedures such as [cardiogenic shock-STEMI]. This is not the case in the United States and is most certainly a major factor for racial and ethnic differences in outcome.”

It will take more than “changes in public education, medical practice, and protocols” to eliminate disparities, Spaulding concludes. “Cardiologists and medical organizations should be actively involved in supporting increase[s] in health insurance coverage. Act now for the benefit of your patients.”

The [current study] is beautiful in that it teases out the noxious interaction of these demographic factors that have nothing to do with the disease process. Saraschandra Vallabhajosyula

Ya’qoub, too, noted that insurance plays a pivotal role. Although their data set only extends to late 2015, she believes that, if anything, the situation has grown worse in recent years, as people have lost coverage in the US. “We saw many patients coming to the hospital because they ran out of their medications, they’re not taking them, their insurance is not helping them, [or] their copay is sky high,” said Ya’qoub.

In terms of what individual clinicians can do, and how receptive they’ll be toward acknowledging their own implicit biases, Ya’qoub said that is a challenge: “I think maybe a lot of physicians don’t realize it. We think we’re doing so great and saving lives.” To get a more-realistic picture, doctors must take a look at what happens at their hospitals, since data can be persuasive, she suggested. “See how you’re doing. It will be eye-opening.”

The acuity of presentation with AMICS, where decisions have to be made rapidly and best practices are evolving, increases the potential for uneven care, said Vallabhajosyula.

“You layer that with people who are from lower-income households or people of nonwhite race, who often have poorer social support systems, especially [when they’re women], who are often single parents or leading the family in some shape or form,” and there can be delays in treatment or poor primary prevention, he said, because work and family responsibilities may get in the way of seeking care, even more so when symptoms are atypical.

“The [current study] is beautiful in that it teases out the noxious interactions of these demographic factors that have nothing to do with the disease process,” said Vallabhajosyula.

He emphasized that physicians should encourage patients to obtain primary prevention and to take their symptoms seriously. “Once people come to the hospital, I think it’s important as physicians or healthcare systems caring for these patients that we routinely recognize and try to eliminate these biases,” Vallabhajosyula advised. “There’s no perfect solution: no human being is perfect, no system is perfect. But we all have to strive to be better today than we were yesterday.”