From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.M., A.Y.C., L.T., T.Y.W., K.L.T., M.T.R., E.D.P.); and National Heart Centre Singapore, Singapore (C.T.C.).
Circulation. 2014 Aug 19;130(8):659-67. doi: 10.1161/CIRCULATIONAHA.113.008370. Epub 2014 Jul 7.
Blacks are less likely than whites to receive coronary revascularization and evidence-based therapies after acute myocardial infarction, yet the impact of these differences on long-term outcomes is unknown.
We linked Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry data to national Medicare claims, creating a longitudinal record of care and outcomes among 40 500 patients with non-ST-segment-elevation myocardial infarction treated at 446 hospitals to examine mortality and readmission rates (mean follow-up, 2.4 years) among black and white patients. Relative to whites (n=37 384), blacks (n=3116) were more often younger and female; more often had diabetes mellitus and renal failure; and received less aggressive interventions, including cardiac catheterization (60.7% versus 54.0%; P<0.001), percutaneous coronary intervention (32.1% versus 23.8%; P<0.001), and coronary bypass surgery (9.2% versus 5.7%; P<0.001). Although blacks had lower 30-day mortality (9.1% versus 9.9%; adjusted hazard ratio, 0.80; 95% confidence interval, 0.71-0.92), they had higher observed mortality at 1 year (27.9% versus 24.5%; P<0.001), although this was not significant after adjustment on long-term follow-up (hazard ratio, 1.00; 95% confidence interval, 0.94-1.07). Black patients also had higher 30-day (23.6% versus 20.0%; P<0.001) and 1-year (62.0% versus 54.6%; P<0.001) all-cause readmission, but these differences were no longer significant after risk adjustment on 30-day (hazard ratio, 1.02; 95% confidence interval, 0.92-1.13) and long-term (hazard ratio, 1.05; 95% confidence interval, 1.00-1.11) follow-up.
Although older blacks with an acute myocardial infarction had lower initial mortality rates than whites, this early survival advantage did not persist during long-term follow-up. The reasons for this are multifactorial but may include differences in comorbidities and postdischarge care.
非 ST 段抬高型心肌梗死患者黑人比白人更不可能接受冠状动脉血运重建和循证治疗，但这些差异对长期预后的影响尚不清楚。
我们将快速不稳定型心绞痛患者危险分层以抑制不良结局并早期实施美国心脏病学会/美国心脏协会指南（CRUSADE）登记数据与全国医疗保险索赔数据相关联，创建了 446 家医院治疗的 40500 例非 ST 段抬高型心肌梗死患者的护理和结局的纵向记录，以检查黑人与白人患者的死亡率和再入院率（平均随访 2.4 年）。与白人（n=37384）相比，黑人（n=3116）患者更年轻、女性居多；更常见的合并症包括糖尿病和肾衰竭；接受的介入治疗也较少，包括心导管检查（60.7%比 54.0%；P<0.001）、经皮冠状动脉介入治疗（32.1%比 23.8%；P<0.001）和冠状动脉旁路移植术（9.2%比 5.7%；P<0.001）。尽管黑人患者的 30 天死亡率较低（9.1%比 9.9%；调整后的危险比，0.80；95%置信区间，0.71-0.92），但他们在 1 年时的死亡率较高（27.9%比 24.5%；P<0.001），尽管在长期随访时经调整后并不显著（危险比，1.00；95%置信区间，0.94-1.07）。黑人患者的 30 天（23.6%比 20.0%；P<0.001）和 1 年（62.0%比 54.6%；P<0.001）全因再入院率也较高，但在 30 天（危险比，1.02；95%置信区间，0.92-1.13）和长期（危险比，1.05；95%置信区间，1.00-1.11）随访时经风险调整后这些差异不再显著。
尽管患有急性心肌梗死的老年黑人患者的初始死亡率低于白人，但这种早期生存优势在长期随访中并未持续。其原因是多方面的，但可能包括合并症和出院后护理的差异。
