Letter by Ferdinand et al Regarding Article, “Does Black Ethnicity Influence the Development of Stent Thrombosis in the Drug-Eluting Stent Era?”
To The Editor:
Blacks have the highest coronary heart disease mortality of major US race/ethnic groups, and represent appropriate candidacy for drug-eluting stents (DES). We read with interest the recent report by Collins et al,1 which concludes that black race is an independent predictor of definite DES thrombosis. Although interesting, this single-center, retrospective analysis contained a relatively small number of black subjects (n=1594) and even fewer stent thrombosis events (n=108). Though provocative, these findings may still represent a play of chance, and should not yet be translated into clinical dogma. The avoidance of DES in black patients who are otherwise appropriate candidates would be yet another misstep consistent with our ongoing disparate care concerns.
Because of these disparate care concerns, the American College of Cardiology launched credo (Coalition to Reduce Disparities in CV Outcomes) as an initiative to provide the tools needed to improve disparities in CV practices (www.cardiosource.org/credo).2 These disparities are troubling and persistent; however, performance-based quality improvement, cultural competency training, team-based care, and patient education are potential interventions to reduce CVD disparities and improve outcomes.
We find this report of racial differences with regard to in-stent thrombosis intriguing, less so for its findings and more so because it highlights the need for precision and sensitivity when race-based data are used. The greater prevalence of black comorbidities (eg, hypertension, diabetes mellitus, heart failure), variations in medication access and compliance, and the complexities of socioeconomic status all represent confounders that cannot be fully accommodated in any multiple regression model. Finally, self-identified, mutually exclusive race assignment is problematic. For instance, in the patient population of the current report, ie, Washington, DC, self-identified blacks include not only African Americans, but blacks of Ethiopian, Caribbean, Somalian, and Nigerian ancestry, in addition to individuals of mixed race.
For these data and all ongoing race/ethnicity-based analyses, it is now imperative that we more fully understand and acknowledge the significant influence of the social determinants of health outcome; we must relinquish our enthusiasm to quickly implicate underlying race-based biological mechanisms and consider the cultural context and ecology of health in our discussions.
We appreciate the efforts of the investigators to bring these data forward, but would caution all to strive for a better understanding of the underpinnings of race/ethnicity-based differences in cardiovascular care and outcomes. We should not be coerced by probability values. As practitioners responsible for the leading cause of death and disability in the United States, it is our duty to deliver the highest-quality and evidence-based care for our patients, regardless of self-identified racial/ethnic, gender, or socioeconomic status.
Coalition to Reduce Disparities in CV Outcomes Advisory Group
Keith C. Ferdinand, MD, FACC
Morehouse School of Medicine
Clyde W. Yancy, MD, MSc, FACC, FAHA, MACP
Feinberg School of Medicine
Tracy Y. Wang, MD, MHS, MSc, FACC
Duke Clinical Research Institute
Dr Ferdinand has relationships with Daiichi Sankyo, Lilly, Astra Zeneca, Novartis, Forest, Takeda, and Genentech-Roche. Dr Wang has relationships with BMS-Sanofi, Schering/Merck, The Medco, Heartscape, Eli Lilly/Daiichi, Canyon, and AstraZeneca. Dr Yancy reports no conflicts.
- © 2011 American Heart Association, Inc.
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