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(Circulation. 2005;111:1225-1232.)
© 2005 American Heart Association, Inc.

Coronary Heart Disease

Racial Variations in Treatment and Outcomes of Black and White Patients With High-Risk Non–ST-Elevation Acute Coronary Syndromes

Insights From CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?)

Ali F. Sonel, MD; Chester B. Good, MD, MPH; Jyotsna Mulgund, MS; Matthew T. Roe, MD, MHS; W. Brian Gibler, MD; Sidney C. Smith, Jr, MD; Mauricio G. Cohen, MD; Charles V. Pollack, Jr, MD, MA; E. Magnus Ohman, MD; Eric D. Peterson, MD, MPH, for the CRUSADE Investigators

From the Center for Health Equity Research and Promotion, Pittsburgh, Pa (A.F.S., C.B.G.); the Division of Cardiology and Duke Clinical Research Institute, Durham, NC (J.M., M.T.R., E.D.P.); the University of Cincinnati School of Medicine, Cincinnati, Ohio (W.B.G.); the University of North Carolina School of Medicine, Chapel Hill, NC (S.C.S., M.G.C., E.M.O.); Wayne State University School of Medicine, Detroit, Mich (R.J.Z.); and the Department of Emergency Medicine, Pennsylvania Hospital, Philadelphia, Pa (C.V.P.).

Correspondence to Ali F. Sonel, VA Pittsburgh Healthcare System, University Drive Division, 111C-U, Pittsburgh, PA 15240. E-mail ali.sonel{at}med.va.gov

Received September 30, 2004; revision received January 12, 2005; accepted January 13, 2005.

Background— Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non–ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes.

Methods and Results— Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37 813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, ß-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients.

Conclusions— Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.

Key Words: ethnic groups • coronary disease • therapy • myocardial infarction

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