Elsevier

American Heart Journal

Volume 246, April 2022, Pages 82-92
American Heart Journal

Clinical investigations
Association between race/ethnicity and income on the likelihood of coronary revascularization among postmenopausal women with acute myocardial infarction: Women's health initiative study

https://doi.org/10.1016/j.ahj.2021.12.013Get rights and content

Background

Historically, race, income, and gender were associated with likelihood of receipt of coronary revascularization for acute myocardial infarction (AMI). Given public health initiatives such as Healthy People 2010, it is unclear whether race and income remain associated with the likelihood of coronary revascularization among women with AMI.

Methods

Using the Women's Health Initiative Study, hazards ratio (HR) of revascularization for AMI was compared for Black and Hispanic women vs White women and among women with annual income <$20,000/year vs ≥$20,000/year over median 9.5 years follow-up(1993-2019). Proportional hazards models were adjusted for demographics, comorbidities, and AMI type. Results were stratified by revascularization type: percutaneous coronary intervention and coronary artery bypass grafting(CABG). Trends by race and income were compared pre- and post-2010 using time-varying analysis.

Results

Among 5,284 individuals with AMI (9.5% Black, 2.8% Hispanic, and 87.7% White; 23.2% <$20,000/year), Black race was associated with lower likelihood of receiving revascularization for AMI compared to White race in fully adjusted analyses [HR:0.79(95% Confidence Interval:[CI]0.66,0.95)]. When further stratified by type of revascularization, Black race was associated with lower likelihood of percutaneous coronary intervention for AMI compared to White race [HR:0.72(95% CI:0.59,0.90)] but not for CABG [HR:0.97(95%CI:0.72,1.32)]. Income was associated with lower likelihood of revascularization [HR:0.90(95%CI:0.82,0.99)] for AMI. No differences were observed for other racial/ethnic groups. Time periods (pre/post-2010) were not associated with change in revascularization rates.

Conclusion

Black race and income remain associated with lower likelihood of revascularization among patients presenting with AMI. There is a substantial need to disrupt the mechanisms contributing to race, sex, and income disparities in AMI management.

Introduction

Social determinants of health are pertinent to acute myocardial infarction (AMI), given their relationship to accessing healthcare and attaining good health outcomes.1., 2., 3. Intersections of race, gender, and income disparities have been well documented in receipt of cardiovascular procedures.4., 5., 6., 7., 8. These studies have found that Black individuals are less likely than White individuals to receive various invasive cardiac procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG).7 Likewise, gender differences were also noted in the literature. Prior research has shown that women with AMI experienced more reperfusion therapy delays than men.9., 10., 11. Similarly, individuals with lower income have a lower probability of undergoing revascularization procedures.12 Receiving timely and appropriate therapy when presenting with AMI has a beneficial impact on health outcomes. Given the disparities in healthcare delivery and access.13,14 national initiatives6,15 such as Health People 2010 have been implemented to ameliorate such inequalities by setting goals to improve access to revascularization therapies for AMI.16,17

While reducing racial and socioeconomic disparities has been a national priority, relatively few longitudinal studies have assessed changes in receipt of AMI therapy. Previous reports suggest that racial disparities persist in coronary revascularization timing, rates, and outcomes.18., 19., 20. A recent comprehensive meta-analysis identified low income as having a predominantly adverse association with myocardial infarction risk factors, incidence, and survival.21 Studies analyzing the previously noted disparity trends among patients with AMI in the last decade (2010-2020) are limited.

Addressing revascularization for an indication, AMI, that is generally appropriate is essential to help uncover the true racial, ethnic, and income disparities. Large national studies suggest that, among nonacute settings, PCI is inappropriate in 12% of the cases, and the appropriateness is uncertain in 38% of cases.22 Therefore, racial/ethnic- and income-based differences in the receipt of coronary revascularization for treatment of AMI were examined using the Women's Health Initiative study (WHI), the largest longitudinal study of postmenopausal women. We hypothesized that Black women, Hispanic women, and women with <$20,000 annual income would receive less revascularization than White women and women with ≥$20,000 when presenting with AMI. Secondarily, we hypothesized that trends in revascularization have improved in the last decade compared to the preceding decade.

Section snippets

Data source

The WHI is a national health study sponsored by the National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI). It is a study of United States postmenopausal women followed for greater than 20 years to evaluate cardiovascular disease (including coronary heart disease, congestive heart failure, stroke, angina, peripheral vascular disease, carotid artery disease, coronary revascularization), cancer, and osteoporosis.23 The original study is one of the largest

Cohort characteristics

Among WHI participants, 5,284 participants (age 66.3 ± 6.8 years; 502 Black race, 147 Hispanic ethnicity, and 4,635 White race) developed AMI over the span of this analysis (Table I). The majority of participants with AMI had an income greater than $20,000 (76.8%), public/no insurance (58.5%), hypertension (50.3%), some college education or higher (72.4%). Compared to women with ≥ $20,000 per year, women with <$20,000 income were more likely to have public/no insurance (73.9% vs 53.9%) and less

Discussion

In a large cohort of postmenopausal women with AMI, Black women and women with <$20,000 annual income were significantly less likely to receive coronary revascularization for AMI than non-Hispanic White women and women with ≥$20,000 annual income. Disparities stratified by revascularization type were significant only among Black and White women receiving PCI. Disparities were not attenuated by accounting for social determinants of health such as education, insurance, and did not change after

Conclusion

Among postmenopausal women participating in one of the largest and longest population studies of women, we found that Black race and income <$20,000 were associated with lower likelihood of coronary revascularization among patients presenting with AMI than patients with White race and income ≥$20,000 respectively. No significant differences were observed among patients of Hispanic ethnicity and Non-Hispanic White ethnicity. Our findings suggest that race and income merit consideration in the

A short list of WHI investigators

Program Office: Jacques Rossouw, Shari Ludlam, Dale Burwen, Joan McGowan, Leslie Ford, and Nancy Geller (National Heart, Lung, and Blood Institute, Bethesda, Maryland).

Clinical Coordinating Center: Garnet Anderson, Ross Prentice, Andrea LaCroix, and Charles Kooperberg (Fred Hutchinson Cancer Research Center, Seattle, WA).

Investigators and Academic Centers: JoAnn E. Manson (Brigham and Women's Hospital, Harvard Medical School, Boston, MA); Barbara V. Howard (MedStar Health Research

Funding

Dr. Breathett has research funding from National Heart, Lung, and Blood Institute (NHLBI) R56HL159216, K01HL142848, R25HL126146 subaward 11692sc, and L30HL148881; and Women As One. The Women's Health Initiative program is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services through contracts HHSN268201100046C, HHSN268201100001C, HHSN268201100002C, HHSN268201100003C, HHSN268201100004C, and HHSN271201100004C.

Conflict of interest

None reported

Acknowledgments

We express gratitude towards the WHI participants, clinical sites, investigators, and staff of which otherwise this study would not be possible.

References (50)

  • N Akhter et al.

    Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

    Am heart j

    (2009)
  • KM Rose et al.

    Neighborhood socioeconomic and racial disparities in angiography and coronary revascularization: the ARIC surveillance study

    Annals of epidemiology

    (2012)
  • F Kilpi et al.

    Early-life and adult socioeconomic determinants of myocardial infarction incidence and fatality

    Soc Sci Med

    (2017)
  • H Jneid et al.

    Committee Members of 2017 AHA/ACC clinical performance and quality measures for adults with ST-Elevation and Non ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on performance measures

    J Am Coll Cardiol [Internet]

    (2017)
  • E Framke et al.

    Contribution of income and job strain to the association between education and cardiovascular disease in 1.6 million Danish employees

    Eur Heart J

    (2020)
  • JW Magnani et al.

    Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the American Heart Association

    Circulation

    (2018)
  • MM Safford et al.

    Number of Social Determinants of Health and Fatal and Nonfatal Incident Coronary Heart Disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

    Circulation

    (2021)
  • G Graham et al.

    Population-level differences in revascularization treatment and outcomes among various United States subpopulations

    World J Cardiol

    (2016)
  • JA Singh et al.

    Trends in and disparities for acute myocardial infarction: an analysis of Medicare claims data from 1992 to 2010

    BMC Med

    (2014)
  • N Hess et al.

    The impact of race on outcomes of revascularization for multivessel coronary artery disease

    The Annals of thoracic surgery

    (2020)
  • M Alkhouli et al.

    Trends in characteristics and outcomes of patients undergoing coronary revascularization in the United States, 2003-2016

    JAMA Netw Open

    (2020)
  • G. Graham

    Acute coronary syndromes in women: recent treatment trends and outcomes

    Clinical Med Insights: Cardiol

    (2016)
  • EP Havranek et al.

    American Heart Association Council on Quality of C, Outcomes Research CoE, Prevention CoC, Stroke Nursing CoL, Cardiometabolic H, Stroke C. Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association

    Circulation

    (2015)
  • K Pahigiannis et al.

    Progress Toward Improved Cardiovascular Health in the United States: Healthy People 2020 Heart Disease and Stroke Objectives

    Circulation

    (2019)
  • Gallery LI, People eLearning H, Workgroup FI, Agencies LF. Visit coronavirus. gov for the latest Coronavirus Disease...
  • Cited by (6)

    • Contributions of the Women's Health Initiative to Cardiovascular Research: JACC State-of-the-Art Review

      2022, Journal of the American College of Cardiology
      Citation Excerpt :

      For example, neighborhood disadvantage in SES and food environments are associated with greater rates of obesity and hypertension,88 and differences in income and prevalent diabetes largely explain the excess HF risk among Black women compared with White women in WHI.32 More recently, we identified persistent race and income disparities in coronary revascularization following acute MI, despite the national Healthy People initiative to ameliorate disparities in clinical cardiac interventions by 2020.89 WHI investigators, therefore, remain committed to utilizing the unique and extensive data resource for ongoing structural-level SDOH research90.

    View full text