Pamboukian Salpy V, Costanzo Maria Rosa, Meyer Peter, Bartlett Linda, McLeod Mary, Heroux Alain
Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois 60612, USA.
J Card Fail. 2003 Apr;9(2):80-6. doi: 10.1054/jcaf.2003.11.
Differences in mortality are thought to exist between African Americans and Caucasians with heart failure. These differences may be due to a variety of factors, including differences in disease process, socioeconomic status, and access to health care. Additionally, little data exist on racial differences between these two groups after cardiac transplantation. This study examines a single center, urban experience in treating African Americans and Caucasians with heart failure and after cardiac transplantation. We hypothesize that treatment in a specialized, comprehensive heart failure/cardiac transplantation program results in similar survival between African Americans and Caucasians.
We retrospectively reviewed the Rush Heart Failure and Cardiac Transplant Database from July 1994 to August 2000. Variables analyzed in the cardiomyopathy patients included survival (until death, placement of left ventricular assist device or cardiac transplantation), number of hospitalizations per year, length of stay per year, and utilization of outpatient resources. Follow-up period was from initial visit to death, transplantation, or implantation of left ventricular assist device. In those who underwent cardiac transplantation, we examined rejection rates (cellular and humoral), rejection burden, hospitalization data, and 5-year survival. A subgroup bridged to cardiac transplantation with a left ventricular device was also analyzed.
Seven hundred thirty-four cardiomyopathy patients were identified: 203 were African Americans and 531 were Caucasians. The etiology of cardiomyopathy was more commonly ischemic in Caucasians as compared to non-ischemic in African Americans (P <.01). African Americans had more admissions to the hospital per year compared with Caucasians, 1.2 +/- 2.1 versus.5 +/- 1.1 (P <.01) with longer length of stay per year, 1.4 +/- 25.2 days versus 4.4 +/- 14.3 days (P <.01). Utilization of outpatient resources was significantly higher in African Americans compared with Caucasians with more use of continuous inotropes (13% versus 6%, P <.01), intermittent inotropes (11% versus 5%, P <.01), and home nursing after hospital discharge (52% versus 32% of hospital discharges, P <.01). Survival by Kaplan-Meier analysis was comparable between the two groups (mean survival 1,470 +/- 72 days in African Americans versus 1521 +/- 46 days in Caucasians, log rank test [P =.6]). During this time, 30 African Americans and 73 Caucasians underwent cardiac transplantation. Fifty-three were bridged to transplantation with a left ventricular assist device (20 African Americans, 33 Caucasians). There were no differences in 5-year survival by Kaplan-Meier analysis despite higher peak preoperative panel reactive antibody levels in African Americans versus Caucasians (12% +/- 30% compared with 5% +/- 15%, P =.04), more overall treated rejection episodes per year in the African Americans (P <.01), as well as more posttransplant hospitalizations (2.2 +/- 1.2 times per year as compared with 1.7 +/- 2.1 times per year, P =.04).
Delivery of care to heart failure patients in a comprehensive, specialized program results in similar survival regardless of race despite higher utilization of inpatient and outpatient resources. The finding that, after cardiac transplantation, African Americans do not have higher mortality rates, despite having higher rates of rejection overall and more hospitalizations, further supports the hypothesis that optimal care can improve outcomes despite unfavorable baseline clinical characteristics.
人们认为非裔美国人和白人在心力衰竭方面存在死亡率差异。这些差异可能归因于多种因素,包括疾病进程、社会经济地位以及获得医疗保健的机会不同。此外,关于这两组人群心脏移植后的种族差异数据很少。本研究考察了一个单一中心针对非裔美国人和白人心力衰竭患者及心脏移植后的城市治疗经验。我们假设在一个专门的、综合性的心力衰竭/心脏移植项目中进行治疗,非裔美国人和白人的生存率相似。
我们回顾性分析了1994年7月至2000年8月的拉什心力衰竭和心脏移植数据库。对心肌病患者分析的变量包括生存率(直至死亡、植入左心室辅助装置或进行心脏移植)、每年住院次数、每年住院时间以及门诊资源的利用情况。随访期从初次就诊至死亡、移植或植入左心室辅助装置。对于接受心脏移植的患者,我们检查了排斥反应发生率(细胞性和体液性)、排斥反应负担、住院数据以及5年生存率。还对一组通过左心室装置过渡到心脏移植的亚组进行了分析。
共确定了734例心肌病患者:203例为非裔美国人,531例为白人。与非裔美国人非缺血性心肌病相比,白人缺血性心肌病的病因更为常见(P<.01)。非裔美国人每年的住院次数多于白人,分别为1.2±2.1次和0.5±1.1次(P<.01),每年的住院时间也更长,分别为1.4±25.2天和4.4±14.3天(P<.01)。与白人相比,非裔美国人门诊资源的利用显著更高,使用持续性正性肌力药物的比例更高(13%对6%,P<.01),间歇性正性肌力药物的比例更高(11%对5%,P<.01),出院后家庭护理的比例更高(占出院人数的52%对32%,P<.01)。通过Kaplan-Meier分析,两组的生存率相当(非裔美国人的平均生存时间为1470±72天,白人的平均生存时间为1521±46天,对数秩检验[P =.6])。在此期间,30例非裔美国人和73例白人接受了心脏移植。53例通过左心室辅助装置过渡到移植(20例非裔美国人,33例白人)。尽管非裔美国人术前群体反应性抗体峰值水平高于白人(12%±30%对5%±15%,P =.04),每年总体治疗的排斥反应发作次数更多(P<.01),移植后住院次数也更多(每年2.2±1.2次对每年1.7±2.1次,P =.04),但通过Kaplan-Meier分析,5年生存率并无差异。
在一个综合性、专门的项目中为心力衰竭患者提供护理,无论种族如何,生存率相似,尽管住院和门诊资源的利用率较高。研究发现,心脏移植后,尽管非裔美国人总体排斥反应发生率较高且住院次数较多,但死亡率并不更高,这进一步支持了以下假设:尽管基线临床特征不利,但最佳护理可改善治疗结果。