Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography

Abstract

Objectives To compare rates of revascularisation in south Asian and white patients undergoing coronary angiography in relation to the appropriateness of revascularisation and clinical outcome. Design Prospective cohort study of patients with two and a half years' follow up; appropriateness of revascularisation rated by nine experts with no knowledge of ethnicity of patient. Setting Tertiary cardiac centre in London with referral from five contiguous health authorities. Participants Consecutive patients (502 south Asian, 2974 white) undergoing coronary angiography in the appropriateness of coronary revascularisation study (ACRE). Main outcome measures Coronary revascularisation, non-fatal myocardial infarction, mortality. Results There was no difference between south Asian and white patients in the proportions deemed appropriate for revascularisation (72% (361) v 68% (2022)) or in the proportions for whom the physician's intended management was revascularisation (39% (196) v 41% (1218)). Among patients appropriate for revascularisation, age adjusted rates of coronary angioplasty (hazard ratio 0.69, 95% confidence interval 0.47 to 1.00, P=0.058) and coronary artery bypass grafting (0.74, 0.58 to 0.91, P=0.007) were lower in south Asian than in white patients. These differences were smaller but still present after adjustment for socioeconomic status and after restriction of analysis to those patients for whom the intended management was revascularisation. There were no differences in mortality and non-fatal myocardial infarction between south Asian and white patients (1.07, 0.78 to 1.47). Conclusion Among patients deemed appropriate for coronary artery bypass grafting, south Asian patients are less likely than white patients to receive it. This difference is not explained by physician bias.

Ethnic differences in utilization of invasive cardiac procedures and in long‐term survival following acute myocardial infarction

“…16 Among patients in whom revascularization was considered appropriate, South Asians were less likely to undergo the procedure, particularly CABG, than whites in the United Kingdom. 5 However, there was no difference in mortality and nonfatal MI, in contrast to our findings. We cannot directly attribute the excess fatality in Malays to their lower rates of revascularization because of strong forces of selection and the persistence of ethnic differences after adjustment for revascularization.…”

“…There are significant differences in the use of invasive cardiac procedures following MI between black and white patients in the United States, 4 and between white and South Asians in the United Kingdom. 5 However, there is little information on the utiliza-tion of revascularization procedures following MI in other ethnic groups and on possible inequalities in survival.…”

Invasive cardiac procedure use and mortality among South Asian and Chinese Canadians with coronary artery disease

“…The surname algorithms are known to be reasonably reliable and valid, with 90.5% sensitivity, 99.4% specificity and 63.2% positive predictive value for South Asian ethnicity (12); and 77.7% sensitivity, 99.7% specificity and 80.5% positive predictive value for Chinese ethnicity (11). Surname methodologies have been used in many previous studies assessing ethnicity in relation to health service use, population health status and risk factors for heart disease (6,(13)(14)(15)(16)(17).…”

Equity of Access to CVD Risk Management Using Electronic Clinical Decision Support in the Coronary Care Unit

“…Internationally, there is evidence that attendance at cardiac rehabilitation post myocardial infarction is less in ethnic minorities and those from poorer areas who would benefit most [5,7]. Furthermore there is evidence in New Zealand and elsewhere that there are inequalities in access to invasive management of CVD according to ethnicity [14,15] and socioeconomic status [16]. A critical step in correcting these inequalities is systematic access to in-hospital CVD risk management, to ensure that patients leave hospital with appropriate knowledge about CVD risk factors and their management.…”