Blacks, Poor Whites Have Worse Survival After Heart Attack

Marlene Busko

September 21, 2015

NEW HAVEN, CT — For older MI survivors, African Americans of all income levels and poor whites have a significantly shorter life expectancy than other MI survivors, according to the results of a new study[1].

Specifically, 17 years after having an MI at a mean age of 76 years, 9.1%, 7.0%, and 5.4% of whites living in high, medium, and low socioeconomic-status areas, respectively, survived, but only 7.1%, 5.7%, and 5.2% of black patients living in these same areas were alive.

The racial discrepancy in survival was most apparent in younger Medicare patients living in wealthy neighborhoods. Among 65-year-old MI survivors living in wealthy neighborhoods, whites lived 3.25 years longer than blacks. Among same-aged survivors living in poor neighborhoods, whites lived 2.15 years longer than blacks.

Published online September 14, 2015 in Circulation, the study included a representative sample of an elderly Medicare population with MI in the US, Dr Emily Bucholz (Yale University School of Medicine, New Haven, CT) told heartwire from Medscape.

Overall, the researchers showed that black patients were more likely to have cardiovascular risk factors but less likely to receive CABG or PCI. Thus, "efforts aimed at reducing health disparities should target primary prevention and equitable delivery of care after heart attack," she said.

"For cardiologists, it is a wake-up call that poor and African American patients have a shorter life expectancy than [better-off patients] and white patients," senior author Dr Harlan M Krumholz (Yale University School of Medicine) said to heartwire . "If we care about [healthcare] equity, then we need to ensure that these individuals are receiving the highest possible care and recognize that our [healthcare] system is often failing these patients," Krumholz urged.

Race, Socioeconomic Status, and Survival After MI

Although studies have shown that both minority race and poor socioeconomic status are associated with poorer health outcomes, few studies have been large and diverse enough to tease out how each of these variables affects long-term outcomes after MI.

To investigate this, Bucholz and colleagues identified 141,095 participants in the Cooperative Cardiovascular Project who were African American or white and aged 65 to 90 when they were hospitalized for a first MI between 1994 and 1996. The patients lived in all the states in the US and were covered by Medicare fee for service.

A total of 6.3% of the cohort (8894 patients) were black and the remainder (132,201 patients) were white.

Based on census data and zip codes, 7526 white patients (5.7%) and 2315 black patients (26%) had a low socioeconomic status; that is, their median household income was below the 15th percentile. Another 29,415 white patients and 763 black patients had a high socioeconomic status; their median household income was above the 85th percentile. The remaining 95,260 white patients and 5816 black patients had a medium household income between these two limits.

After surviving a heart attack, black patients and patients living in poor socioeconomic areas did not live as long as their white peers. Even black patients living in wealthier neighborhoods had a worse survival after a heart attack, compared with their white neighbors.

Bucholz and colleagues speculate that black patients had a shorter life-span following an MI than white patients for several reasons. More black patients lived in poor socioeconomic areas, which is a risk factor itself. Black patients also had higher rates of comorbidities (including diabetes, hypertension, congestive heart failure, and smoking), and they were less likely to receive PCI or CABG.

However, in older patients, the racial difference in life expectancy narrowed. In fact, the life expectancy of black patients exceeded that of white patients for patients >81 years of age in areas of low median household income, and it exceeded that of white patients >86 years of age in areas of medium median household income (P<0.05).

"The condition of patients at the time of admission and the quality of their care seem to play some role and point to the need to ensure that poor patients and African American patients receive high-quality care before and during hospitalizations for [acute] MI," Krumholz said. "Disparities in this country are costing certain groups years of life. Moreover, the [racial] disparity [in life expectancy after MI] is about more than income. It's time for us to address these issues directly."

The study was sponsored by grants from the National Heart, Lung, and Blood Institute and the National Institute of General Medical Sciences Medical Scientist Training Program. Krumholz received research agreements from Medtronic and from Johnson & Johnson through Yale University to develop methods of clinical-trial data sharing. He also works under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures and is chair of a cardiac scientific advisory board for UnitedHealth. Disclosures for the coauthors are listed in the paper


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