Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
University of Missouri-Kansas City School of Medicine, Kansas City.
JAMA Netw Open. 2018 Nov 2;1(7):e184240. doi: 10.1001/jamanetworkopen.2018.4240.
Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI).
To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018.
Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates.
Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P < .001). Most categories of patient characteristics differed substantially between black patients and white patients. The cumulative propensity score discriminated race, with a C statistic of 0.89, and the propensity scores were associated with 1- and 5-year mortality rates (hazard ratio for the 75th percentile of the propensity score vs 25th percentile, 1.72; 95% CI, 1.43-2.08; P < .001). Patients in the lowest propensity score quintile associated with being a black individual (regardless of whether they were of white or black race) had a 5-year mortality rate of 15.5%, while those in the highest quintile had a 5-year mortality rate of 31.0% (P < .001). After adjusting for the propensity associated with being a black patient, there was no significant mortality rate difference by race (adjusted hazard ratio, 1.09; 95% CI, 0.93-1.26; P = .37) and no statistical interaction between race and propensity score (P = .42).
Characteristics of black patients and white patients differed significantly at the time of admission for AMI. Those characteristics were associated with an approximately 3-fold difference in 5-year mortality rate following AMI and mediated most of the observed mortality rate difference between the races.
急性心肌梗死（AMI）后，黑人患者的预后比白人患者差。
研究非种族特征在多大程度上解释了 AMI 后白人患者和黑人患者之间观察到的生存差异。
设计、地点和参与者：这项队列研究使用了广泛的社会经济和临床特征，这些特征来自于 2003 年至 2008 年期间在美国连续 31 家医院接受 AMI 康复治疗的患者前瞻性收集的数据，用于 Prospective Registry Evaluating Myocardial Infarction：Events and Recovery 注册和 Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status 注册。使用国家死亡指数的数据来评估生存情况。数据分析于 2016 年 12 月至 2018 年 7 月进行。
患者特征分为 8 个领域，通过计算与每个领域的黑人种族相关的倾向得分，以及跨所有领域的累积倾向得分，确定每个领域将自我认定的黑人患者与白人患者区分开来的程度。最终的倾向得分与 1 年和 5 年的死亡率相关。
在 6402 名患者（平均[SD]年龄，60[13]岁；2127[33.2%]名女性；1648[25.7%]名黑人）中，AMI 后 5 年死亡率为 28.9%（1648 名中的 476 名）黑人患者和 18.0%（4754 名中的 856 名）白人患者（风险比，1.72；95%置信区间，1.54-1.92；P<0.001）。黑人和白人患者的大多数患者特征类别差异很大。累积倾向得分可以区分种族，C 统计量为 0.89，并且倾向得分与 1 年和 5 年的死亡率相关（第 75 百分位与第 25 百分位的倾向得分之比的风险比，1.72；95%置信区间，1.43-2.08；P<0.001）。处于与黑人个体相关的最低五分位数倾向得分的患者，5 年死亡率为 15.5%，而处于最高五分位数倾向得分的患者，5 年死亡率为 31.0%（P<0.001）。在调整与黑人患者相关的倾向得分后，种族之间的死亡率没有显著差异（调整后的风险比，1.09；95%置信区间，0.93-1.26；P=0.37），种族和倾向得分之间没有统计学上的相互作用（P=0.42）。
AMI 入院时黑人患者和白人患者的特征差异显著。这些特征与 AMI 后 5 年死亡率约 3 倍的差异相关，并介导了种族之间观察到的大部分死亡率差异。
