Impact of Race on Cardiac Care and Outcomes in Veterans With Acute Myocardial Infarction

OBJECTIVES: The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system. DESIGN: Retrospective cohort study using clinical data. SETTING: Eighty-one acute care VA hospitals. PATIENTS: Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients. MAIN OUTCOME MEASURES: Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years. RESULTS: Black patients were equally likely to receive beta-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%; P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups. CONCLUSIONS: In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.