Published online before print March 31, 2008, doi: 10.1161/CIRCULATIONAHA.107.726562
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(Circulation. 2008;117:1787-1801.)
© 2008 American Heart Association, Inc.
Coronary Heart Disease |
Impact of Ethnicity and Gender Differences on Angiographic Coronary Artery Disease Prevalence and In-Hospital Mortality in the American College of Cardiology–National Cardiovascular Data Registry
From Emory University (L.J.S., P.C.B.), Atlanta, Ga; Sutter Pacific Heart Centers (R.E.S.), San Francisco, Calif; Cedars-Sinai Medical Center (C.N.B.M.), Los Angeles, Calif; Oakland Medical Center (R.G.B.), Oakland, Calif; Rush University Medical Center (L.W.K.), Chicago, Ill; University of Michigan Medical Center (B.N.), Ann Arbor, Mich; Duke University Medical Center (P.S.D., E.D.P.), Durham, NC; Washington University (R.J.K.), St. Louis, Mo; Harbor-UCLA Medical Center (C.R.M.), Los Angeles, Calif; American College of Cardiology (K.H.), Washington, DC; and Christiana Healthcare (W.S.W.), Wilmington, Del.
Correspondence to Leslee J. Shaw, PhD, Emory Program in Cardiovascular Outcomes Research and Epidemiology, 1256 Briarcliff Rd NE, Suite 1-N, Emory University School of Medicine, Atlanta, GA 30306. E-mail lshaw3{at}emory.edu
Received July 11, 2007; accepted February 8, 2008.
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Abstract |
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Background— Although populations referred for coronary angiography are increasingly diverse, there is limited information on coronary artery disease (CAD) prevalence and in-hospital mortality other than for predominately white male patients.
Methods and Results— We examined gender and ethnic differences in CAD prevalence and in-hospital mortality in a prospective cohort of patients referred for angiographic evaluation of stable angina (n=375 886) or acute coronary syndromes (ACS; unstable angina or myocardial infarction, n=450 329) at 388 US hospitals participating in the American College of Cardiology–National Cardiovascular Data Registry, an angiographic registry. Univariable and multivariable (with covariates that included risk factors, symptoms, and comorbidities) logistic regression models were used to estimate significant CAD, defined as 
70% stenosis, and in-hospital mortality. Within stable angina and ACS cohorts, 7% of patients were black, 2% were Hispanic, 0.3% were Native American, 1% were Asian, and 90% were white, respectively. In stable angina, the risk-adjusted OR for significant CAD was 0.34 for women compared with men (P<0.0001), with black women having the lowest risk-adjusted odds (P<0.0001) compared with other females. Among ACS patients, the risk-adjusted OR of significant CAD was 0.47 for women compared with men (P<0.0001); similarly, black women had the lowest risk-adjusted odds (P<0.0001) compared with other females. Higher in-hospital mortality was reported for white women presenting with stable angina (P<0.00001). White women had a 1.34-fold (95% CI 1.21 to 1.48) higher risk-adjusted odds ratio for mortality than white men with stable angina (P<0.0001), with higher rates noted for white women who were older or had significant CAD (both P<0.0001). Lower utilization of elective coronary revascularization, aspirin, and glycoprotein IIb/IIIa inhibitors (all P<0.0001) may have contributed to higher in-hospital mortality for white women. In ACS, higher in-hospital mortality was reported for Hispanic (P=0.015) and white (P<0.0001) women; however, neither white (P=0.51) or Hispanic (P=0.13) women had higher in-hospital risk-adjusted mortality.
Conclusions— The likelihood for significant CAD at coronary angiography and for in-hospital mortality varied significantly by ethnicity and gender. Future clinical practice guidelines should be tailored to gender subsets of the population, in particular for black women, to improve the efficient use of angiographic laboratories and to target at-risk populations of women and men.
Key Words: ethnicity • gender • mortality • angina • coronary disease • angiography
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Introduction |
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Cardiac catheterization ranks as the most common hospital procedure for patients, with a total of 1 687 000 procedures, and it is performed in 12% of all discharged hospital patients, as reported in 2004.1,2 Despite an increasingly ethnically diverse US population, our current understanding of ethnic differences in the extent and severity of coronary artery disease (CAD) is based predominantly on white male populations. Population studies and clinical trial data have noted significantly greater coronary disease mortality in women than in men, specifically in black patients.3–5 Prior studies have noted more cardiac risk factors, including more frequent clustering of risk factors, in blacks, yet a paradoxically lower prevalence of obstructive and subclinical CAD.6–10 Despite the available evidence,11–17 few reports have discussed differences in the prevalence of obstructive CAD by ethnicity in a contemporary, geographically diverse coronary angiography registry.17–20 Therefore, we sought to compare differences in the rate of significant CAD and in-hospital mortality by ethnicity and gender in 2 subsets of patients evaluated for stable and unstable chest pain syndromes and prospectively enrolled in the American College of Cardiology’s (ACC) National Cardiovascular Data Registry (NCDR CathPCI Registry).
Clinical Perspective p 1801
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Methods |
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Patient Entry Criteria
Patient entry was limited to 2 distinct patient cohorts: (1) those referred for elective, diagnostic coronary angiography with suspected, yet stable chest pain symptoms (n=375 886) and (2) those referred after admission for an acute coronary syndrome (ACS), including acute myocardial infarction or unstable angina (n=450 329). Patients were enrolled in version 2.0 of the NCDR registry from quarterly consecutive series of patients undergoing coronary angiography from 2000 to 2002. Patients were excluded if they were referred for (1) evaluation before valvular surgery or (2) evaluation of other diseases of the heart, including transplant, congenital disease, or cardiomyopathic abnormalities.
Data Elements and Collection Methods of the NCDR
The NCDR CathPCI Registry captures 142 clinically pertinent and standardized data elements that are needed to detail and assess the quality of care for patients receiving diagnostic coronary angiography. Risk factor and past medical history were derived from patient interview, medical records, or both. Definitions for risk factors and all other data elements within the NCDR registry are available online (http://www.accncdr.com/WebNCDR/elements.aspx; accessed March 13, 2008). Details of the CathPCI Registry and copies of the case report form may be found on the ACC’s NCDR Web site.21 Since 1998, enrollment in the NCDR has grown to >600 participant hospitals, free-standing laboratories, and adult cardiology practices representing 
20% of all US facilities that perform cardiac catheterization. Participating institutions use ACC-certified commercially available software that is deemed compliant with clinical and coding data standards set forth by the ACC. NCDR-participating institutions collect and submit quarterly patient data using ACC-certified software programs. Within this cohort, ethnicity was recorded as defined by the patient. The present report includes consecutively enrolled patients from 388 US hospitals.
Coronary Angiography Procedures
Coronary angiography was performed and reviewed at the clinical sites according to accepted methods put forth by the ACC.22 All coronary segments were interpreted visually at each participating site. Percent stenosis in each of the major epicardial coronary arteries was estimated and entered into the ACC case report form. Left ventricular ejection fraction was calculated by the area-length method.22 These registry data reflect ongoing care of patients undergoing coronary angiography at 388 US hospitals. As such, coronary angiography and the analysis of the presence of significant CAD was not interpreted in a manner blinded to the patient’s name, gender, or ethnicity.
Definitions
Major coronary arteries analyzed were the left anterior descending, left circumflex, and right coronary arteries. Significant CAD was defined as 70% stenosis in any of the major epicardial coronary arteries.
Statistical Methods
Continuous variables were expressed as mean±SD, and categorical variables were presented as frequencies. Continuous and categorical measures were compared with t tests, ANOVA, or 
2 statistic, as appropriate. Initial analysis included comparisons of the clinical, angiographic, and procedural complication data for each ethnic subset of the population. Additionally, laboratory, hospital, and healthcare payer characteristics were compared within ethnic subsets.
One aim of the present study was to estimate gender and ethnic differences in significant CAD defined at coronary angiography. A second aim was to evaluate the variability of in-hospital mortality by ethnicity and gender. Univariable and multivariable logistic regression models were used to estimate (1) significant CAD and (2) in-hospital mortality. From the models, an OR and 95% CI were calculated. To examine gender and ethnicity effects, we included the main effect terms (ie, gender and separate variables for each ethnic subset), as well as separate gender interaction terms for black, Hispanic, Asian, and Native American women. Risk adjustment included consideration of candidate variables with a univariable P<0.10. Risk-adjusted models were chosen a priori to reflect clinically significant variables, including traditional cardiac risk factors and chest pain or dyspnea symptoms. We also included geographic, laboratory, hospital, healthcare payer, and physician characteristics in the multivariable models. Volume measurements, such as the number of hospital beds or full-time employees, were categorized into quartiles. A 2-sided P<0.05 was considered statistically significant. Data were analyzed with SPSS version 15.0 (Chicago, Ill).
The authors had full access to the data and take full responsibility for its integrity. All authors have read and agree to the manuscript as written.
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Results |
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Stable Chest Pain Cohort (n=375 886)
Clinical Characteristics in the Diagnostic Cohort
Compared with white, non-Hispanic patients, ethnic minority patients (except Asians) were on average 2 to 4 years younger (P<0.0001) and had higher rates of hypertension and diabetes (all P<0.001). Black, Hispanic, and Native American patients had an average body mass index
30 kg/m2, which met criteria for obesity; however, Asian patients had a significantly lower body mass index than other subsets within this cohort. Although higher rates of heart failure symptoms were noted in ethnic minority patients, rates of stable angina varied by ethnicity. Higher rates of renal failure were reported in black, Hispanic, Native American, and Asian patients (P<0.001). White, non-Hispanic patients had a greater frequency of stress-induced ischemia (P<0.0001). (See Table 1).
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Laboratory, Hospital, and Payer Characteristics for Ethnic Subsets
Ethnic minority patients were hospitalized 0.3 to 0.9 days longer than their white, non-Hispanic counterparts (P<0.0001). Ethnic minorities (except Asian patients) more often underwent angiography at a teaching hospital (P<0.0001). Significant variability in the geographic distribution of ethnic minority patients was noted (P<0.0001). Black patients were more often from the Southeast and Great Lakes regions of the United States. Hispanic and Asian patients were more often from the Western states region. Native American patients were more often from the West and Central region. Finally, 5.2% to 8.5% of black, Hispanic, and Native American patients had no healthcare insurance (P<0.0001). Information on laboratory, hospital, and payer characteristics is included in the Appendix in the online Data Supplement.
Procedural Complication Rates
Unplanned coronary artery bypass surgery rates were low (
0.4%) but were slightly higher among white, non-Hispanic patients (P<0.0001; Table 2). Postprocedure renal failure did not differ by ethnicity (P=0.13).
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In-Hospital Mortality Rates
Higher in-hospital mortality rates were reported for white women who presented with stable angina (0.6% versus 0.5% for men, P<0.00001), with no gender differences noted for other ethnic subsets (all P>0.15; Figure 1). Table 3 depicts a multivariable model that examines the impact of gender and ethnicity on in-hospital mortality. Predictors of in-hospital mortality included age, obstructive CAD, history of noncardiac atherosclerosis, and other cardiac risk factors. Patients treated for hyperlipidemia (P<0.0001) had lower odds of in-hospital mortality, as did younger obese patients (P=0.003).
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In a risk-adjusted model, white women had a 1.34-fold (95% CI 1.21 to 1.48) greater OR for mortality than white men (P<0.0001). In those with stable chest pain, white women with 1-, 2-, and 3-vessel CAD, respectively, had a 1.67-fold (95% CI 1.10 to 2.53), 1.83-fold (95% CI 1.24 to 2.69), and 2.02-fold (95% CI 1.28 to 3.18) higher OR for in-hospital mortality than white men (P=0.013). Moreover, older white women had higher mortality rates. Specifically, higher in-hospital mortality was reported for white women 70 to 79 years old (OR 2.15, 95% CI 1.46 to 3.16, P<0.0001) and for those 80 years old (OR 3.85, 95% CI 2.22 to 6.70, P<0.0001) than for black women. Similarly, white women 80 years of age and older had 6.30-fold (95% CI 2.58 to 15.41) increased OR of in-hospital death compared with similarly aged Asian women (P<0.0001).
In-Hospital Coronary Revascularization and Aspirin and Glycoprotein IIb/IIIa Therapy Utilization Rates
For stable chest pain patients, utilization rates for elective and emergent percutaneous coronary intervention and CABG surgery were higher for men than for women across all ethnic subsets; however, the risk-adjusted OR (controlling for variables noted in Table 3) were mostly lower for white women undergoing elective coronary revascularization (P<0.0001 for both) and for use of aspirin (P<0.0001) and glycoprotein IIb/IIIa inhibitors (P<0.0001). With regard to the latter, differences in utilization of IIb/IIIa inhibitors were largely due to lower in-laboratory use in women than in men of diverse ethnicity (all P<0.0001).
Frequency of Significant CAD by Gender and Ethnicity
Of the 375 886 patients, 58.7% had significant CAD. The rate of significant CAD was 48.8% for women and 66.7% for men (P<0.0001; Figure 2A), which resulted in an unadjusted OR of 0.37 (95% CI 0.366 to 0.38) in women compared with men (P<0.0001).
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Of the 207 564 men enrolled in the ACC-NCDR registry, black men had the lowest prevalence of disease, with only 52.2% having obstructive CAD. By comparison, 64.2% and 67.6% of Hispanic and white men and nearly 75% of Native American and Asian males had significant CAD at angiography. For each ethnic subset, the overall rate of significant CAD was higher for men than for women (P<0.0001).
Among the 168 322 women, black women also had the lowest rate of obstructive disease, with only 41.7% having significant CAD at angiography. Similarly, 45.3% of Hispanic women had significant CAD, whereas the rates of obstructive CAD were 55%, 53%, and 50% for Native American, Asian, and white, non-Hispanic women, respectively.
Risk-Adjusted Gender and Ethnic Differences in Significant CAD
In a multivariable model, traditional risk factors, metabolic syndrome risk factors, and noncardiac atherosclerosis were significantly associated with higher OR of significant CAD (Table 5). In addition, typical angina, imaging ischemia, and presentation with heart failure symptoms were also associated with higher odds of significant CAD. Nonclinical factors associated with more frequent significant CAD included being uninsured, performance of angiography at a government or community hospital, and performance of angiography at a larger hospital with more beds and employees.
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The risk-adjusted OR for significant CAD was 0.34 for women compared with men (P<0.0001). In this multivariable model, the sole gender-by-ethnicity interaction that remained significant was that for black women (OR 0.64, P<0.0001). For black women, higher ORs for significant CAD included chronic lung disease (OR 1.3, P<0.0001), hyperlipidemia (OR 1.3, P<0.0001), insulin-dependent diabetes mellitus (OR 2.4, P<0.0001) and non–insulin-dependent diabetes mellitus (OR 1.7, P<0.0001), heart failure symptoms (OR 1.6, P<0.0001), and typical angina (OR 1.7, P<0.0001). Additionally, the OR for significant CAD increased by age decile (Figure 3) such that black women 70 to 79 years of age and 80 to 98 years old had a 3.6- to 5.7-fold higher OR for significant CAD (P<0.0001 for both age deciles).
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ACS Cohort (n=450 329)
Clinical Characteristics in the Acute Chest Pain Cohort
In the ACS cohort, ethnic minorities (except Asians) were generally younger and had a higher body mass index (Table 6). More than half of Native American patients had diabetes or prior myocardial infarction, and Native Americans were more often referred to catheterization on an urgent basis and more often received preangiography thrombolysis. Asian patients were more often transferred from another facility for the procedure and were more likely to have cardiogenic shock as an indication for angiography. Black patients more often had heart failure and unstable angina as presenting symptoms. Finally, white, non-Hispanic patients more often had a prior revascularization procedure.
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Laboratory, Hospital, and Payer Characteristics for Ethnic Subsets
Ethnic minority patients had a longer average length of stay and more often underwent the procedure at an urban location. More than 90% of patients underwent the procedure with onsite surgical backup, although this rate was lowest for black patients. Black patients were also more likely to undergo the procedure at a government hospital. Hispanic, Asian, and Native American patients more often underwent the procedure at lower-volume facilities with fewer hospital beds. Information on laboratory, hospital, and payer characteristics are included in the Appendix in the online Data Supplement.
Procedural Complication Rates
Ethnic differences were noted across an array of procedural complications, including postprocedure myocardial infarction (P=0.003) and unplanned CABG surgery (P<0.0001) or emergent percutaneous coronary intervention (P<0.0001; Table 7). In general, higher complication rates were observed for white patients, except that postprocedural renal failure and vascular bleeding occurred more frequently in Hispanic, Native American, and Asian patients. Additionally, postprocedural shock and in-hospital death were reported more often in Hispanic and Asian patients.
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In-Hospital Mortality Rates
Although the rates of all-cause (P=0.026) and cardiac (P=0.041) death were significantly different across ethnic subsets, these differences were not significant in a risk-adjusted model that controlled for age, gender, and cardiogenic shock on referral (P=0.47 for all-cause death and P=0.98 for cardiac death). A multivariable model of significant estimators of in-hospital death is detailed in Table 8. In this model, female gender remained a significant predictor of in-hospital death (P<0.0001) after risk adjustment for an array of risk factors, comorbidities, symptoms, and nonclinical factors. In this risk-adjusted model, Hispanic women exhibited a trend toward worsening in-hospital mortality (P=0.13).
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Higher unadjusted mortality was reported for white women than for men (P<0.0001; Figure 1), with these results persisting in a multivariable model that compared in-hospital mortality differences in white women and men (OR 1.32, 95% CI 1.25 to 1.39, P<0.0001). In a stepwise model, angiography performed on an urgent or emergent basis (OR 4.09, 95% CI 3.76 to 4.44, P<0.0001) and presentation in cardiogenic shock (OR 12.46, 95% CI 11.24 to 13.80, P<0.0001) were the single greatest estimators of in-hospital mortality for white women. After these, each decile of age for white women was associated with a 1.79-fold (95% CI 1.72 to 1.85) higher OR of in-hospital death (P<0.0001). In-hospital death rates ranged from 3.0% for white women <50 years of age to 33.9% and 37.4% for women 70 years old and 80 years of age, respectively (P<0.0001). Additionally, white women with angiographic CAD had higher odds of in-hospital mortality; for white women, each vessel with a 70% stenosis was associated with a 1.57-fold (95% CI 1.51 to 1.64) higher OR of in-hospital mortality (P<0.0001). For white women, in-hospital mortality rates were 7.7%, 22.4%, 31.8%, and 38.0% for <70% stenosis and 1-, 2-, and 3-vessel CAD, respectively (P<0.0001).
In-Hospital Coronary Revascularization and Aspirin and Glycoprotein IIb/IIIa Therapy Utilization Rates
For ACS patients, utilization rates for elective and emergent percutaneous coronary intervention and coronary bypass surgery were higher for men than for women across all ethnic subsets (Table 8); however, the risk-adjusted OR (controlling for variables noted in Table 8) were mostly lower for white women undergoing elective coronary revascularization (P<0.0001 for both) and for use of aspirin (P<0.0001) and glycoprotein IIb/IIIa inhibitors (P<0.0001). With regard to the latter, differences in utilization of IIb/IIIa inhibitors were largely due to lower in-laboratory use in women than in men of diverse ethnicity (all P<0.0001).
Frequency of Significant CAD by Gender and Ethnicity
Similar to the diagnostic cohort, women of diverse ethnicities had a lower frequency of significant CAD (P<0.0001; Figure 2B). Only 64.2% and 68% of black and Hispanic women, respectively, had significant CAD, rates that were significantly less than for other women in the present ACS cohort. The unadjusted OR for significant CAD was 0.59 for black women (P<0.0001), 0.86 for Hispanic women (P<0.0001), 1.04 for Native American women (P=0.53), and 1.09 for Native American women (P=0.028) compared with white, non-Hispanic females, respectively.
Risk-Adjusted Gender and Ethnic Differences in Significant CAD
In the present cohort of 450 329 patients presenting with ACS, a number of clinical and nonclinical factors were associated with significant CAD (Table 10). Clinical predictors included diabetes, noncardiac atherosclerosis, renal failure, and a prior history of CAD. Patients presenting with non–ST-segment and ST-segment myocardial infarction had a 3.4-fold (P<0.0001) and 6.9-fold (P<0.0001) elevated OR of significant CAD. Nonclinical factors associated with a higher OR of significant CAD included being uninsured (P=0.001) or undergoing the procedure at a community hospital (P<0.0001) with a higher percentage of Medicare patients (P<0.0001), higher percutaneous coronary intervention volume (P=0.044), and onsite coronary bypass surgery (P<0.0001).
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Similar to the diagnostic cohort, the risk-adjusted OR of significant CAD was 0.47 for women compared with men (P<0.0001). Only black women had a lower OR (0.67, P<0.0001) for significant CAD after controlling for other clinical and nonclinical covariates. Among the 11 556 black women, those with a higher OR for significant CAD included those with chronic lung disease (OR 1.3, P<0.0001), hyperlipidemia (OR 1.4, P<0.0001), and diabetes therapy with (OR 2.1, P<0.0001) or without (OR=1.5, P<0.0001) insulin or combination diabetes therapy (OR=1.7, P<0.0001). Additionally, the OR for significant CAD increased by age decile (Figure 3) such that black women 70 to 79 years old and 80 to 98 years old had a 3.05- to 5.06-fold higher OR for significant CAD, respectively (P<0.0001 for both age deciles).
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Discussion |
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Within the last decade, the lack of gender-specific evidence prompted an upsurge in research focusing on clinical differences in cardiovascular disease between women and men.23–27 In a similar manner, our current knowledge about differences in CAD and clinical outcomes by ethnicity is notably inadequate given the recent population shifts in Hispanic, Asian, and other diverse patient cohorts.6,8,9,28–33 The current catheterization data set from the ACC-NCDR, given its nationwide coverage, is uniquely suited to provide insight into differences across gender and ethnic patient subsets referred for coronary angiography.21 From 2 large angiographic cohorts of patients with stable chest pain (n=375 886) and ACS (n=450 329), in-hospital mortality rates varied by gender and ethnicity, with the highest event rates noted for older white women with obstructive CAD. Moreover, black women had significantly lower rates of obstructive CAD (ie, risk-adjusted OR
0.65). We believe that this evidence should prompt the development of predictive models for in-hospital mortality and significant CAD that are guided by the unique risk factors within each gender and ethnically diverse cohort.
Role of Gender and Ethnicity in In-Hospital Mortality
Since the mid-1980s, the total number of deaths related to cardiovascular disease has been greater for women than for men.20 For example, in 2002, 50 000 more women than men died of cardiovascular disease. It has been reported that cardiovascular death rates have not declined as much for women of diverse racial subsets as for white women and men.34,35 In stable chest pain patients in the present study, crude in-hospital death rates were higher for women than for men, but this failed to reach statistical significance for all but white women (P<0.0001). These data extend prior reports that have focused on ACS populations25,35–39 but provide insight into lower-risk, stable chest pain patients. White patients were at least 2 years older than ethnic minority patients, which may be a principal driver for outcome differences across population subsets in the present study. The present results reveal that elderly white women had an elevated OR of in-hospital death, as much as 6.3-fold higher, compared with similarly aged black and Asian women (P<0.0001).
Furthermore, in stable chest pain patients, white women with angiographic CAD were also at higher risk of in-hospital mortality. Among patients with stable chest pain, white women with 1- to 3-vessel CAD had 1.67- to 2.02-fold higher in-hospital mortality than white men (P=0.013). In particular, for white women, lower utilization of aspirin and glycoprotein IIb/IIIa inhibitor therapies may have contributed to mortality differences. These data support an expanding evidence base, indicating that women with significant atherosclerosis have a worsening clinical outcome.24,25 Recent reports also note that higher-risk women with extensive coronary calcification have higher mortality rates than men.40,41
For higher-risk women presenting with ACS, a similar pattern was noted in which only white women had higher in-hospital mortality. Certainly, the advanced age at presentation for white women played a key role in clinical outcome, with nearly one third of white females 70 years of age and older dying in the hospital (P<0.0001). However, in a stepwise model, the greatest predictors of in-hospital mortality for white women were angiography performed on an urgent or emergent basis (OR 4.09, P<0.0001) and presentation in cardiogenic shock (OR 12.46, P<0.0001). Of the more than 1 million hospitalizations for acute myocardial infarction, more men are admitted annually19,20; however, 1-year death rates are consistently higher for women, particularly for black women.19,20,24 The present report did not highlight an early hazard for black women, and it remains possible that less intensive postdischarge care may place these women at risk for near- and long-term postdischarge death.
Role of Gender and Ethnicity in Obstructive CAD
Despite cardiovascular disease being the leading killer of women at all ages, the prevalence of obstructive CAD in women is low. From the present report, when we controlled for an array of clinical and nonclinical factors, including insurance coverage and laboratory volume, the OR for significant CAD was reduced by >50% in women compared with men presenting with stable chest pain symptoms and for those with ACS. This pattern of a lower frequency of significant CAD in the setting of stable chest pain and ACS has been reported previously.24,42,43 Recent data from the National Institutes of Health–National Heart, Lung-and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation reported that nearly two thirds of females undergoing elective coronary angiography had nonobstructive CAD.44 Similarly, women enrolled in the Thrombolysis In Myocardial Infarction-18 and Global Utilization of Streptokinase and t-PA for occluded arteries randomized trials had 47% and 57% lower frequencies of significant CAD, respectively, compared with men.42 A recent synthesis of ACS trials reveals that on average, 23% of women and 13% of men had nonobstructive CAD.45
Although this consistent pattern of a lower frequency of significant CAD has been reported for several decades, what is yet to be defined is how ethnicity may alter this gender relationship to angiographic CAD. The present results further revealed that black and Hispanic patients had a lower prevalence of CAD than their white, non-Hispanic counterparts when referred for evaluation of stable and unstable chest pain symptoms. These results were similar to a prior report in 311 men referred to coronary angiography after a positive nuclear imaging study.46 In that report by Whittle et al46 from a cohort of male veterans, blacks had a 17% lower rate of significant CAD.
However, within these 2 large cohorts, black women had the lowest observed frequency of significant CAD, with only 42% and 64% presenting with stable and unstable chest pain symptoms, respectively. Our test for interaction revealed that black women had an OR for significant CAD of 0.64 (P<0.0001) with stable chest pain and 0.67 with ACS (P<0.0001). These results in ethnic minorities, notably for black women, may be the result of a limited knowledge base in important diverse subsets of the patient population.28 A less abundant evidence base may contribute to precatheterization pathways that are less efficient or care pathways that may be based on physician indecision. A prior report by Barnhart and Bernstein47 noted that among patients who met appropriate clinical criteria for coronary angiography, blacks and Hispanics were less likely to be referred to cardiac catheterization. In a similar report, guidelines oriented toward black post–myocardial infarction patients resulted in a similar yield in identifying patients with significant CAD,48 thus supporting the concept that tailored pathways may improve detection of patients at risk for significant CAD.
Evidence reported herein further identifies subsets of black women with a higher OR for significant CAD. In both the stable and unstable cohorts, black women with diabetes, chronic lung disease, or hyperlipidemia consistently had a higher OR for significant CAD. The presence of a higher risk of CAD with diabetic and hyperlipidemic blacks has been reported in several prior series49; however, data specific to women are ill-defined. Significant CAD also increased with age, with elderly black women having a 3- to 6-fold higher OR. Observed frequencies revealed that nearly 60% and >75% of elderly black women with stable chest pain or ACS, respectively, had significant CAD, rates that more closely approximated those of their male counterparts.
Study Limitations
Given the present large cohort of patients undergoing coronary angiography, statistical differences are frequently observed but may not be clinically meaningful. For example, in large cohorts such as this, even 1% to 2% differences in the prevalence of risk factors or other comorbidities may be statistically significant yet insignificant from a clinical perspective. Although data are available from population samples, one cannot draw inferences from the present study registry and apply them to noncatheterized patients owing to referral bias.23 A major limitation of the present data is that participation in the NCDR is voluntary and not without selection bias. We included only hospitals that provide consecutive patient series on a quarterly basis to minimize selection bias. Moreover, our prognostic models only considered the dichotomous occurrence of in-hospital death, because of the largely short observation time period, and the models did not consider a differential timing of this event.
The registry contains a limited depth of information on risk factors and other measured risk factor data, as well as about the reason and timing of referral and may underestimate clinical risk prediction. We used in-hospital all-cause mortality as an end point in an attempt to minimize event misclassification. Results for cardiac-specific mortality may be different from the presented results. These data also represent patients referred for coronary angiography, and as such, the present results are in part due to selection bias. Moreover, risk factor and additional medical history were often derived from patient self-reports and are therefore subject to bias. We believe that this may explain, for example, why patients with chronic lung disease had lower odds of CAD. Finally, the use of visual angiographic interpretation may differentially bias the present results for gender and ethnic subsets of these 2 cohorts. The exclusion of measured arterial diameters may have resulted in differential bias across gender and ethnic patient subsets.
Conclusions
The present report provides an exploration of differential in-hospital mortality and angiographic CAD rates in 2 large, ethnically diverse cohorts of 375 886 and 450 329 patients referred to coronary angiography for evaluation of stable and unstable chest pain syndromes. The present study was the first to evaluate in-hospital death rates in lower-risk patients with stable chest pain symptoms and revealed generally similar outcomes for women and men of diverse ethnicity. However, white women with stable and unstable chest pain symptoms, particularly those with angiographic CAD, had higher in-hospital mortality. Similarly, white women presenting with ACS who required angiography on an urgent or emergent basis and those presenting in cardiogenic shock were particularly at risk of in-hospital death.
Substantial ethnic and gender-related differences were also notable across the present registry, including a lower (risk-adjusted) OR of significant CAD in black women. Of clinical importance, elderly black women had significantly higher CAD rates, and it was possible to identify subsets of these women with higher disease prevalence that approached the rate of their male counterparts. This evidence illustrates the prominent role of ethnicity and gender in defining diagnostic strategies for significant CAD detection and may be helpful in updating the expected rates of significant CAD for women and men of diverse ethnicity referred for diagnostic coronary angiography. The present mortality and CAD predictive models have important implications for clinical practice and support the need for individualized gender- and ethnicity-based risk profiles in clinical care algorithms.
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Acknowledgments |
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Disclosures
None.
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References |
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Footnotes |
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The online-only Data Supplement, consisting of an Appendix, is available with this article at http://circ.ahajournals.org/cgi/content/full/ CIRCULATIONAHA.107.726562/DC1.
Preliminary results were presented at the 77th Annual Scientific Sessions of the American Heart Association, November 7–10, 2004, New Orleans, La.
Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.
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