Treatment in universities and academic centers may be associated with a reduction in racial or ethnic disparities in long-term major adverse cardiovascular events (MACE) or cardiovascular disease (CVD) mortality among women with obstructive coronary artery disease (CAD), new research suggests.
An analysis of 364 women with obstructive CAD found that Black race was associated with the same risk for MACE (hazard ratio [HR], 0.87) after adjustment for age and CV risk factors and a similar risk for CVD mortality (age-adjusted HR, 1.56) as non-Black race.
“It was surprising to find that despite black women having a relatively higher burden of CV risk factors and overall lower socioeconomic position, compared to non-Black women, long-term CVD outcomes were similar,” lead author Judy M. Luu, MD, PhD, junior scientist at McGill University Health Centre in Montreal, Canada, told Medscape Medical News.
“This key point supports emerging areas of intervention that could impact outcomes, including education,” she said. “It also supported the hypothesis that other risk factors contribute to CVD, beyond the traditional ones, including perhaps experience of systemic racism.”
The study was published online October 25 in the Canadian Journal of Cardiology.
Similar Outcomes
The investigators studied 944 women (mean age, 58 years; 17% non-Hispanic black) enrolled in the Women’s Ischemia Syndrome Evaluation (WISE). Of those 944, more than one third (38%) had obstructive CAD.
Among the participants with CAD, black women (mean age, 59 years) had a higher BMI (31.4 vs 28.8), greater prevalence of high blood pressure (89.7% vs 63.5%), and higher rates of use of ACE inhibitors or angiotensin II receptor blockers (ARB, 82.6% vs 63.4%) compared with non-Black women. Statin, beta-blocker, calcium-channel blocker, and hormone replacement therapy use did not differ between black women and non-Black women.
In addition, a larger proportion of Black women had lower levels of education (50% vs 18.5%), lower levels of income, and public health insurance.
The primary outcome, MACE, included all-cause mortality, nonfatal myocardial infarction, stroke, and hospitalization for angina or heart failure. This outcome occurred in 47 Black women (68%) with CAD and 173 non-Black women (58.6%) with CAD.
Among patients with CAD, Black race was associated with the same risk for MACE (age-adjusted HR, 1.15). After accounting for age and CV risk factors, the adjusted HR was 0.87, driven largely by angina hospitalization (50.7% in black vs 33.8% in non-Black women).
Age and Duke Activity Status Inventory were independent predictors of long-term MACE at 10 years for both groups. Race or ethnicity, however, were not predictors.
Furthermore, use of ACE inhibitors/ARB, beta-blockers, calcium channel blockers, or hormone replacement therapy did not predict outcomes. Baseline statin use, the exception, was associated with increased risk for MACE in the adjusted model (HR, 1.62).
Black race also was associated with a similar risk for the secondary outcome, CV mortality, with an age-adjusted HR of 1.56.
“We postulate that black women with CAD treated in university/academic centers experience less racial and ethnic discrimination and receive appropriate guideline-directed therapy,” write the authors. “Physician and community education campaigns should be instituted to mitigate structural racism in CVD in community health care settings.”
“There are numerous reports that quality of care and resultant outcomes are better in academic healthcare settings, despite the training of medical students and physicians and nurses that may sometimes lead to more mistakes,” study co-author Noel Bairey-Merz, MD, director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles, told Medscape. “These studies support the contention that high quality care that improves outcomes can be learned and is not inherent or due to magic.”
In a proposed study, Luu, who is co-chair of the Canadian Women’s Heart Health Alliance, and colleagues aim to develop “a comprehensive and improved primary prevention risk assessment tool for women across their lifespan that considers the relationship between sex, gender, psychosocial, environmental factors, and socioeconomic position, risk factors that are not routinely asked about during a medical examination.
The Canadian Women’s Heart Health Alliance “has developed resources in 17 languages to raise awareness about CVD in women and reduce barriers for women of different ethnicities,” she added. She suggests that, among other strategies, clinicians use Google Translate or another translation software regularly in their practices.
Prospective Trials Needed
“The small sample size, and the fact that other relevant CV risk factors previously associated with adverse CV events were not included, represent significant limitations of this study,” write Amélie Paquin, MD, MSc, of the Quebec Heart and Lung Institute, and colleagues in an accompanying editorial.
“For instance, lipid and glucose profiles, previous adverse pregnancy outcomes, and lifestyle habits were not addressed in this secondary analysis. Information regarding severity of CAD was also not provided. These elements could have influenced the incidence of MACE outcomes differentially between black and non-Black women.”
Nevertheless, they added, “This study…is of great interest, as the author raises an important and still unanswered question pertaining to the impact of quality of care on CV outcomes among black women: Do academic centers provide more inclusive cardiovascular care than community centers?”
Dr Roxana Mehran
Commenting on the study for Medscape, Roxana Mehran, MD, director of interventional cardiovascular research and clinical trials at the Icahn School of Medicine at Mount Sinai in New York City, said, “This study is woefully underpowered to answer the questions regarding non-White women with CAD. While they do not observe differences in outcomes in these women, compared with White women, this does not mean that this difference is not there. The time has come for us to focus on these women and perform studies powered to answer this important question.” Mehran did not participate in the research.
“We need prospective trials with large numbers of diverse women included,” she said. “At this point, we are still not clear if disparities exist in treatment of CAD in non-White women.”
The study was supported by contracts from the US National Heart, Lung, and Blood Institutes, a General Clinical Research Center grant from the National Center for Research Resources, the National Center for Advancing Translational Sciences, the Department of Defense, the Gustavus and Louis Pfeiffer Research Foundation, the Women’s Guild of Cedars-Sinai Medical Center, the Ladies Hospital Aid Society of Western Pennsylvania, QMED, the Edythe L. Broad and the Constance Austin Women’s Heart Research Fellowships, Cedars-Sinai Medical Center, the Barbra Streisand Women’s Cardiovascular Research and Education Program, Cedars-Sinai Medical Center, the Society for Women’s Health Research, the Linda Joy Pollin Women’s Heart Health Program, the Erika Glazer Women’s Heart Health Project, and the Adelson Family Foundation.
Luu disclosed no relevant financial relationships. Bairey-Merz is a member of the board and holds stock in iRhythm and is a consultant for SHL Telemedicine. Paquin and colleagues report no relevant financial relationships.
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