Racial Disparities in the Utilization and Outcomes of Temporary Mechanical Circulatory Support for Acute Myocardial Infarction-Cardiogenic Shock

Abstract

Racial disparities in utilization and outcomes of mechanical circulatory support (MCS) in patients with acute myocardial infarction-cardiogenic shock (AMI-CS) are infrequently studied. This study sought to evaluate racial disparities in the outcomes of MCS in AMI-CS. The National Inpatient Sample (2012–2017) was used to identify adult AMI-CS admissions receiving MCS support. MCS devices were classified as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) or extracorporeal membrane oxygenation (ECMO). Self-reported race was classified as white, black and others. Outcomes included in-hospital mortality, hospital length of stay and discharge disposition. During this period, 90,071 admissions were included with white, black and other races constituting 73.6%, 8.3% and 18.1%, respectively. Compared to white and other races, black race admissions were on average younger, female, with greater comorbidities, and non-cardiac organ failure (all p < 0.001). Compared to the white race (31.3%), in-hospital mortality was comparable in black (31.4%; adjusted odds ratio (aOR) 0.98 (95% confidence interval (CI) 0.93–1.05); p = 0.60) and other (30.2%; aOR 0.96 (95% CI 0.92–1.01); p = 0.10). Higher in-hospital mortality was noted in non-white races with concomitant cardiac arrest, and those receiving ECMO support. Black admissions had longer lengths of hospital stay (12.1 ± 14.2, 10.3 ± 11.2, 10.9 ± 1.2 days) and transferred less often (12.6%, 14.2%, 13.9%) compared to white and other races (both p < 0.001). In conclusion, this study of AMI-CS admissions receiving MCS devices did not identify racial disparities in in-hospital mortality. Black admissions had longer hospital stay and were transferred less often. Further evaluation with granular data including angiographic and hemodynamic parameters is essential to rule out racial differences.

Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals

“…Insurance status often serves as a surrogate for systematic socioeconomic disparities and therefore reflects the negatively reinforcing influences of age, race, sex, socioeconomic status, and access to health care as demonstrated in literature. 26,38,[44][45][46][47] In addition to the above factors, provider perception of medical adherence may influence the final decision on whether PCI is offered to this population. Given the disastrous effects of stent thrombosis when dual antiplatelet therapy is not followed, providers may be apprehensive to offer PCI to a patient who may or may not be able to afford the needed medications.…”

“…This is particularly important since age is a strong risk factor for worse outcomes in AMI-CS. 6,9,26,44,46,47,52,53 By reducing such confounders, directly comparing populations, using a database without enriching specific populations, and collecting a large nationwide population data, this study describes the disparities associated with lack of insurance for these critically ill patients.…”

“…22 Demographic characteristics, hospital characteristics, acute organ failure, mechanical circulatory support, cardiac procedures, and noncardiac organ support use were identified for all admissions using previously used methodologies from our group. 23–39…”

“…22 Demographic characteristics, hospital characteristics, acute organ failure, mechanical circulatory support, cardiac procedures, and noncardiac organ support use were identified for all admissions using previously used methodologies from our group. [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] The primary outcome was the in-hospital mortality in uninsured AMI-CS admissions compared with private insured individuals. Secondary outcomes included temporal trends in admissions, use of coronary angiography, PCI, MCS, use of donot-resuscitate (DNR) status, palliative care referrals, hospitalization costs, length of hospital stay and discharge disposition in uninsured and privately insured individuals with AMI-CS.…”

Adjusted mortality of extracorporeal membrane oxygenation for acute myocardial infarction patients in cardiogenic shock

“…[9] Studies regarding the comparisons between the use of ECMO and IABP separately in MI-CS revealed a significantly increased risk of 30-day mortality in the ECMO group. [10][11][12][13] One study compared the mortality between ECMO ± IABP and IABP alone (81% vs 74%; P = .5), [14] while another revealed a lower incidence of IABP ± ECMO compared with IABP alone (33% vs 68%; P = .01). [15] However, these observational registry-based studies only reported unadjusted incidences of short-term mortality, which could lead to false interpretations of the effect of ECMO support in MI-CS.…”