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