MACE risk after PCI higher for Black vs. white patients
Black race independently predicted worse outcomes after PCI, according to an analysis of 10 randomized trials that included Black, white, Asian and Hispanic patients.
The analysis, which was published in JACC: Cardiovascular Interventions, found that Black, Hispanic and Asian patients enrolled in these trials had more comorbidities compared with white patients.
“Improving health care and outcomes for minorities is essential, and we are hopeful that our work may help direct these efforts,” Gregg W. Stone, MD, director of academic affairs for the Mount Sinai Heart Health System, professor of medicine (cardiology) and of population health sciences and policy at The Zena and Michael A. Wiener Cardiovascular Institute at Icahn School of Medicine at Mount Sinai, told Healio. “This won’t happen without active concerted efforts to promote change and opportunity, a task for government, regulators, payers, hospital administrators, physicians and all health care providers.”
Trials on coronary artery interventions
Researchers analyzed data from 22,638 patients from 10 prospective, randomized controlled trials focused on coronary artery interventions. Race was either determined by the investigator or self-reported. Comorbidities assessed included CV risk factors and prior cardiac interventions.
Principal outcomes of interest were MI, all-cause death and MACE, defined as a composite of MI, cardiac death or ischemia-driven target lesion revascularization, all of which were assessed at 30 days, 1 year and 5 years.
Of the patients in this analysis, 90.9% were white, 4.1% were Black, 1.8% were Asian and 2.1% were Hispanic.
Angiographic and baseline characteristics were different among groups. Compared with white patients, Black patients were more often younger (59.4 years vs. 62.8 years) and women (42.4% vs. 27.4%), had a higher BMI (31.7 kg/m2 vs. 29.6 kg/m2) and had a higher prevalence of diabetes (42.7% vs. 25%), hypertension (84.6% vs. 67.4%), smoking (33.3% vs. 28.5%) and hyperlipidemia (69% vs. 64.2%).
Hispanic patients, compared with white patients, were more often women (36.8% vs. 27.4%), had a higher BMI (30.3 kg/m2 vs. 29.6 kg/m2) and had a higher prevalence of hypertension (75.9% vs. 67.4%), diabetes (47.4% vs. 25%) and a history of CAD. In contrast, they were less likely to smoke (21.5% vs. 28.5%).
Compared with white patients, Asian patients were less likely to be smokers (20.5% vs. 28.5%), had a lower BMI (25.5 kg/m2 vs. 29.6 kg/m2) and had a higher prevalence of hyperlipidemia (73.8% vs. 64.2%).
At 5 years, MACE occurred in 18.8% of white patients, 23.9% of Black patients (P vs. white patients = .0009), 11.2% in Asian patients (P vs. white patients = .0007) and 21.5% of Hispanic patients (P vs. white patients = .07).
Multivariate analysis determined that Black race was independently associated with increased risk for MACE at 5 years (HR = 1.28; 95% CI, 1.05-1.57).
“Achieving representative proportions of minorities in clinical trials is essential, but has proven challenging,” Stone said in an interview. “We must ensure that adequate numbers of hospitals and providers that are serving these patients participate in multicenter trials. Trust has to be developed so that minority populations have confidence to enroll in studies. Language can be a barrier, requiring translation services and extra time and effort. Involvement of the families and primary care physicians who have an established relationship with patients in clinical trial discussions is useful. For outpatient studies, community outreach may be effective, as seen in the barbershop hypertension trial. Finally, enrollment of ‘non-Hispanic white’ patients can be capped at a certain proportion of the total to ensure adequate enrollment of other racial and ethnic groups.”
‘Crucial and pressing priority’
In a related editorial, Michael G. Nanna, MD, cardiology fellow at Duke University School of Medicine, and Eric D. Peterson, MD, MPH, professor of medicine, Fred Cobb, MD Distinguished Professor of Medicine, core faculty member at Duke-Margolis Center for Health Policy and member in the Duke Clinical Research Institute at Duke University School of Medicine, wrote: “Solving racial health disparities is a crucial and pressing priority for all in health care. The findings from Golomb et al remind us just how large the racial gaps in CVD care and outcomes continue to be. Yet, rather than merely observe these differences over and over again for the next 30 years, there is an urgent need for action to address these both locally and nationally.”
For more information:
Gregg W. Stone, MD, can be reached at firstname.lastname@example.org; Twitter: @greggwstone.