Race-Based Differences in ST-Segment–Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines–Coronary Artery Disease Registry

Abstract

BACKGROUND: Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment–elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. METHODS: We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines–Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to–percutaneous coronary intervention time within 90 minutes; and first medical contact–to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients’ county of residence. RESULTS: Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact–to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12–1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74–1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82–1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85–1.09]). CONCLUSIONS: Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.

The COVID-19 impact on STEMI disparities

“…Socioeconomic status, gender, age, race, and ethnicity are all factors that have all been independently associated with prolonged time to intervention and divergent clinical outcomes [ [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] ]. Disparities in race and/or ethnicity have been shown in various metrics, such as obtaining pre-hospital EKG, as well as in mortality differences [ 35 ]. While there is some evidence to suggest these gaps have narrowed over time with increased awareness, guideline driven care and attempts at national healthcare reform, many disparities have persisted [ [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] ].…”

“…Disparities in race and/or ethnicity have been shown in various metrics, such as obtaining pre-hospital EKG, as well as in mortality differences [ 35 ]. While there is some evidence to suggest these gaps have narrowed over time with increased awareness, guideline driven care and attempts at national healthcare reform, many disparities have persisted [ [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] ].…”