Influence of Race, Sex, and Age on Management of Unstable Angina and Non—Q-Wave Myocardial Infarction

Objective. —To investigate the natural history and response to treatment of patients with unstable angina or non—Q-wave myocardial infarction (MI). Design. —Inception cohort. Setting. —Patients in general community, primary care, or referral hospitals. Patients. —All patients with an episode of unstable exertional chest pain or chest pain at rest presumed to be ischemic in origin lasting 5 minutes or more but without persisting ST-segment elevation greater than 30 minutes or the development of Q-waves were identified and enumerated in 18 participating hospitals. A subset of enumerated patients was selected to be followed prospectively using specific sampling strategies that would provide adequate numbers of black, women, and elderly (aged ≥75 years) patients for comparison with their respective counterparts. Main Outcome Measures.—The primary analysis compared the incidence of death or Ml at 42 days after entry into the prospective study according to race, sex, and age. Other outcomes considered were recurrent ischemia and the combined outcomes of death, Ml, or recurrent ischemia by 42 days after entry. Results. —A total of 8676 admissions with unstable angina or non—Q-wave Ml were enumerated and, of these, 3318 patients were selected for the prospective study. The direct adjusted mean age of the 3318 patients was 63.8 years. There were 943 blacks and 2375 nonblacks. Compared with nonblacks, blacks were less likely to be treated with intensive anti-ischemic therapy for their qualifying anginal episode and less likely to undergo invasive procedures (risk ratio RR, 0.65; 95% confidence interval CI, 0.58 to 0.72;PPConclusions. —Among patients presenting with acute ischemic chest pain without persistent ST-segment elevation, blacks appeared to have less severe coronary disease, received revascularization less frequently, and had less recurrent ischemia compared with nonblacks. Women also were found to have less severe coronary disease and were treated less intensely than men, but experienced similar outcomes. Elderly patients had more severe coronary disease than younger patients on coronary angiography, but were more likely to be treated medically, and they experienced far more adverse outcomes. These data suggest that more aggressive strategies should be directed to those patients with the greatest likelihood of adverse outcomes. (JAMA. 1996;275:1104-1112)