Do Racial Differences in Revascularization Procedures after Acute Myocardial Infarction Lead to Racial Disparities in Mortality between Black and White Patients: A Qualitative Systematic Review

Background: Several previous studies have shown that black patients receive coronary reperfusion procedures less often than white patients after acute myocardial infarction (AMI). Despite this well documented difference, no evidence has shown a decisive difference in morality rates between black and white AMI patients. Purpose: The purpose of this review is to systematically collect and analyze the current evidence that evaluates racial differences in mortality caused by racial differences in revascularization procedure use between black and white patients presenting with AMI. Methods: A systematic review was conducted by a single reviewer using a MEDLINE literature search to identify observational studies that evaluate black and white patient differences in revascularization procedures and mortality after AMI. A total of 86 citations were reviewed, 42 articles were retrieved, and 11 articles were included from the MEDLINE search. An additional 3 articles were included following a reference list review. Included studies were evaluated for design quality using an abbreviated form of the Scottish Intercollegiate Guidelines Network (SIGN) methodological checklist for cohort studies. Results: 8 of 10 studies evaluating PTCA rates showed that black patients with AMI receive PTCA less often than white patients. 9 of 10 studies evaluating coronary artery bypass graft surgery (CABG) rates showed that black patients with AMI receive CABG less often than white patients. No studies within the review showed a statistically significant difference between black and white patients for in-hospital, 30-day, 1-year, 2-year, 3-year, or 5-year mortality rates. 1 study showed a statistically significant difference of age-adjusted mortality rate per 100 person years for black men (HR 1.34 95% CI 1.18-1.52) and black women (HR 1.22 95% CI 1.06-1.40) compared to white men. Conclusion: Despite evidence to support racial differences in revascularization procedures after AMI, the collection of evidence within this review does not indicate a racial difference in mortality. The similarities in mortality despite differences in standards of care may be explained by a process of selection of healthier black patients secondary to higher rates of out of hospital AMI death among black patients.