Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Abstract

Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates. Design Multicentre cohort with five year follow-up. Setting Six ambulatory care clinics in England. Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method. Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.

Chronic Coronary Artery Disease: Diagnosis and Management

“…106,107 In the United Kingdom, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. 108 Appropriateness of CABG in northern New England in 2008 was 87.7%. 1 In 2006, 253,000 patients underwent CABG in the United States.…”

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

“…To date, there are conflicting reports on the use of and outcomes associated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) among Asian patients with coronary artery disease. Sekhri et al (5) followed up on 263 South Asian and 1112 white patients deemed appropriate for angiography in England, and reported that South Asian patients were less likely to receive angiography than white patients within three years. Feder et al (6) examined 345 South Asian and 2167 white patients undergoing coronary angiography in one health trust in London, England (UK).…”

Presentation of stable angina pectoris among women and South Asian people

“…Causes of death and admission to hospital were coded according to the International Classification of Diseases, 10th revision (ICD-10). Our primary outcome, used in all reports from this data set, 17,22 was death from coronary artery disease (ICD-10 codes I20-I25) as well as hospital admission because of an acute coronary syndrome (acute myocardial infarction, ICD-10 codes I21-I23) and unstable angina (ICD-10 codes I20.0-120.9, 124.0, I24.8, I24.9). The management outcomes were receipt of coronary angiography as a confirmatory diagnostic test and subsequent coronary revascularization (either percutaneous coronary intervention or coronary artery bypass surgery, whichever was first) within 3 years of a clinic visit.…”

“…10,11 This has been attributed to vasospastic and microvascular angina in women 12 and to the higher prevalence of diabetes mellitus 13 and socio-economic deprivation 7 among South Asian people. Both women 14,15 and South Asian 16,17 patients are less likely than men and white people in general to undergo invasive management of angina. It has been proposed that differences in how these patients describe their symptoms may contribute to inequalities in medical care, 8,18 because the diagnostic validity of symptoms plays an important role in deciding appropriate clinical management.…”