COMMENTARY

Tackling BAME Heart Risks: Can Doctors Do More?

Dr Sukh Nijjer

Disclosures

March 17, 2021

This transcript has been edited for clarity.

Hi, I'm Dr Sukh Nijjer. I'm an interventional cardiologist working in central London in the United Kingdom, and welcome to this Medscape UK video.

Today I'm joined by two esteemed colleagues Mamas Mamas from Keele University in the north of England, and Dr Shrilla Banerjee, a consultant cardiologist working in Sussex.

Today we're going to be talking about a very interesting new study that was recently published in Heart , which is a British medical journal. And we're going to be speaking to both Mamas, who is the senior author of this, as well as Dr Banerjee, who has written a very interesting editorial together with Aaysha Cader and Clyde Yancy from the United States. They're going to provide a wider perspective on this study and its findings.

In precis, this study is about racial disparities and the treatment of those patients having acute coronary syndromes, in particular STEMI and NSTEMI, in the United Kingdom. Mamas' group has looked at widely available national registry data and linked that with outcomes to understand what the differences are between different racial groups in the United Kingdom.

What's interesting is they've looked at those findings in the last 3 years, but also in the most recent period when we've been fighting the COVID pandemic.

Thanks for joining us. Mamas, why don't you talk me through what led you to want to do this study and the headline results.

Prof Mamas Mamas

We know from the press and from lots of other scientific studies that the COVID pandemic has disproportionately affected the BAME community, in the UK and elsewhere - across the United States, for example - and there's lots of great data out there to suggest that the mortality in the BAME community is much greater than in Caucasian patients. What we wanted to do was to look at whether in hospital health care systems, such as the National Health care system, there were disparities in care and outcomes in the treatment of acute coronary syndrome in patients of BAME backgrounds. We looked at this using the MINAP registry, which is the UK heart attack registry, and we linked this to Office for National Statistics (ONS). And we saw some quite interesting findings.

First and foremost, there was a significant increase in the proportion of BAME patients that presented with an acute coronary syndrome during the COVID pandemic. We saw that there were disparities in treatment, such as receipt of cardiac catheterisation and PCI, and we also saw an increase in mortality risk compared to the pre-COVID period. I think that's the main headline findings from the study.

Dr Nijjer

Thanks Mamas. I think we should define a few terms. You use the word BAME, and for those members who are watching this video who don't know what that means, we're talking about those individuals of Black, Asian and Minority Ethnic groups. And this is a term that's being used in the United Kingdom, to refer to ethnic minorities of a non-Caucasian background. I personally am not a huge fan of this term, and I know that it's a love or hate term used in the UK. And I know we're moving away from it already. But I think it does usefully summarise this.

Shrilla, what were your take home messages for when you looked at this study?

Dr Shrilla Banerjee

It was a very helpful study, and I'm very grateful to Mamas and his team for performing the research. But the thing that really struck me was the fact that in COVID times this disparity in healthcare outcomes was amplified, but it was present pre-COVID as well. And it just suggests that for some reason, other than a biological reason, there is a worse outcome if you're a Black, Asian or Minority Ethnic patient suffering with ACS in just the times of COVID. Not particularly with the COVID infection, but in the times of the first COVID lockdown.

Dr Nijjer

OK, so let's take a look at the data in a little bit more detail. So, Mamas, in your study you've noticed that there are quite large discrepancies in the risk factor profile of those individuals that come in with an acute coronary syndrome, whether it be NSTEMI, or STEMI. And there are baseline characteristics that are quite different amongst Caucasians and non-Caucasians. Can you talk me through why you think there may be those differences and what impact that might have on the study findings?

Prof Mamas

Generally, patients of Black, Asian, and Minority Ethnic background tend to be younger. So in our study, they're on average 7 years younger than the Caucasian population. They have a much higher risk factor profile. So for example, the prevalence of diabetes is much higher, the prevalence of prior cardiac surgery, PCI, hypertension, is much higher than in the Caucasian population. And clearly, a worse risk factor profile would pertain to worse outcomes. We also saw that patients that were Black, Asian, and Minority Ethnic were more likely to present acutely or with more severe ACS phenotypes, so they were more likely to present with an out of hospital cardiac arrest or with a STEMI. And all these factors drive worse outcomes. Interestingly, the worst outcomes persisted once we had adjusted for these differences in baseline characteristics.

Dr Nijjer

So thanks, Mamas, your group has recognised that these individuals are at high risk. But you've also recognised that despite their high risk, that there are differences in the timeliness of the treatment, and perhaps the quality of the treatment. And your group has published that there are differences in the use of anti-platelets, and the time for angiography, which we would accept is an international standard for the treatment of acute coronary syndromes. Can you expand on that for me?

Prof Mamas

Yes, so patients were far less likely to receive diagnostic cardiac catheterisation, and far less likely to receive PCI and dual antiplatelet therapy treatments. Interestingly, in the group of patients that did receive PCI, there were no differences in mortality outcomes between the BAME population and the Caucasians.

Now, this really makes me think that maybe there's a way, or a reason, by which we stratify these patients. And one of the things that my group is working on currently is to look at the performance in some of the risk scores that are used to guide an invasive management plan, in particular, the GRACE score. Let’s not forget that the GRACE score was developed in Caucasian patients, and actually, it hasn't been validated in Black, Asian, and Minority Ethnic patients. Much of the risk factor profile that drives risk in the GRACE score is age. Whereas we know that Asian patients in particular present much younger with cardiometabolic phenotype that isn't considered in the GRACE score. So I just wonder whether the GRACE score is not fit for purpose in this population, and perhaps may explain why less patients are being referred for cardiac catheterisation and invasive management.

Dr Nijjer

Well, that's an interesting take. So we're seeing an interesting hypothesis there, that there may well be deficiencies in the current scoring systems that we use here in the United Kingdom. GRACE is a very commonly used score, we're actually encouraged to report a GRACE score in every single acute coronary syndrome patient by the National Institute for Health and Care Excellence (NICE), and that, therefore, it weighs heavily in our decision making.

Shrilla, in your editorial, you mentioned some other factors that may well be contributing to the recognition of these patients at an early stage. Can you expand on that, for me?

Dr Banerjee

There are a number of factors that can help explain some of the reasoning behind this disparity in healthcare provision. For instance, there's been a comment about patient-based factors and physician-based factors. Patient-based factors are lack of health care seeking behaviour, and failure to attend in a timely fashion, resulting in a poorer outcome for patients. And so levels of education, that's a key factor in Black and Minority Ethnic patient presentations. And a number of the virus-facing roles - I term them - are more highly represented by Black, Asian and Minority Ethnic patients. So patients who work in transportation, in healthcare, in grocery shops, patients who are exposed to a bigger viral load can be often found to be more from Black, Asian and Minority Ethnic populations.

Dr Nijjer

So you recognise that there are a number of factors that may alter health seeking behaviour, which may be more prevalent in those of a so-called BAME background, which then may alter the way that they attend hospital. Once they're in hospital, is there a deficiency amongst physicians in recognising acute coronary syndromes, or offering treatment? Is that a possible factor?

Dr Banerjee

It seems that physician biases is a player in all of this as well. And really that was the message I wanted to get across from the editorial, and my colleagues who wrote with me, that really we need to look at our own practice, identify our bias, because all of us are guilty of bias. We need to identify it, remove it, and make sure that we provide equal care for every patient coming through our door.

Dr Nijjer

Absolutely. Here in the United Kingdom, where we have a publicly paid for healthcare system with free healthcare delivery at the point of access, really, it would be essential for us to be able to deliver it without any form of bias. For myself, as someone who is of an Asian background, when I read a study like this, I found it profoundly disappointing. And for me, it's quite striking that in the United Kingdom, which is a very cosmopolitan country with a widely mixed population from all over the world, that there could still be disparities like this, that your study has found Mamas.

I wonder whether there is much difference within the different geographies of the United Kingdom. I work in London, which is an incredibly diverse area. And I would say that almost all of the patients that we deal with on a day-to-day basis may be from all over the world, clustered in a single ward or a single heart attack assessment centre. And it's often we have to speak many different languages in a day. Have you noticed that there are geographical variations in the kind of outcomes you were seeing?

Prof Mamas

So we haven't studied geographical differences in this particular project. But clearly, there are differences geographically and by hospital in the management of acute coronary syndrome. One of the papers that we're trying to publish at the moment, we're looking at management by cardiologists of NSTEMI within the first 24 hours, and we've looked at it by individual hospital level. And there's huge differences. I mean, there's hospitals with rates as low as 2-3%, to hospitals with rates of close to 100%. So even though we all work within a single health care system, and we have single guidelines, the actioning of these guidelines seems to be very different in different hospitals. And I have no doubts that there will be hospital level differences in management of patients.

Dr Nijjer

Yes, and even within a hospital, within a large team, there will be variants amongst individuals, some who will take a more aggressive invasive approach very early, whereas those who would prefer to let the patient be treated with antiplatelets first before taking them to the cath lab, particularly in the NSTEMI setting. So Shrilla, in your editorial, you made some suggestions on how we can remove some of this bias. What kind of timeline do you see in us being able to achieve that? And do you think it's realistic?

Dr Banerjee

It's aspirational? I do think we need to address bias. Mamas and myself are working on the next step, which hopefully will be coming out in the near future. I do think, firstly, on a personal level, that's quite an immediate action we can take, we all need to look at our practice and, you know, looking at my own practice, I think as an Asian female, I should be bias free, but I'm not.

So immediately we can all perform our own personal reflection. But long-term, implicit bias training, yes, it is important, but it mustn't be a tick box exercise, it must be something that actually results in change.

Healthcare disparity is not just one factor. There's patient-based factors, which we've identified and we need to address, and that needs societal change. So, thinking about the fact that more Black and Minority Ethnic patients live in overcrowded areas with poor housing and poor exercise spaces. But also thinking as physicians, we have to look into our own practice, and be a little bit introspective, and reflect on our day-to-day challenges that we come across and actually make sure that we be our best selves.

Dr Nijjer

That's a positive way to end this, this video. So I thank the audience and look forward to seeing you again on Medscape. Thank you.

Prof Mamas and Dr Banerjee report no relevant disclosures.

You can follow Dr Sukh Nijjer on Twitter.

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