Examining racial differences in coronary heart disease mortality and acute myocardial infarction recurrence: a community study Open Access
Islek Yaras, Duygu (Summer 2021)
Abstract
Despite considerable improvements in the prevention of coronary heart disease (CHD) over the past decade, significant racial disparities still exist in CHD mortality. The factors driving these inequalities are not well understood. In this dissertation, we examined racial disparities in CHD mortality by focusing on three keys but understudied aspects: hospitalization after presenting to the Emergency Department (ED) for an acute coronary syndrome (ACS), out-of-hospital mortality, and acute myocardial infarction (AMI) recurrence and mortality.
We used data from the Health Care Cost and Utilization Project (HCUP) and the cohort and surveillance components of the Atherosclerosis Risk in Communities (ARIC) Study. In the first study, we examined the ED records of three states, Florida, New York and Utah and found that racial disparities exist in rates of hospitalization among patients who visit the ED and receive a discharge code for ACS. We further report that health insurance does not explain these racial differences. In the second study, we report large differences in fatal incident CHD by race, in contrast to non-fatal incident CHD. Black individuals die from CHD at about twice the rate of White individuals, and the excess in mortality is seen irrespective of where these events occur in or out of the hospital. As a mediator, income explained 39% of racial disparities in out-of-hospital fatal CHD.
In the third study, in four US communities’ part of the ARIC surveillance, Black individuals had higher recurrent and incident AMI rates than White individuals. The magnitude of the racial differences in recurrent AMI rates was more pronounced than incident AMI rates.
Our findings suggest an important area for quality improvement in healthcare. Our findings also provide insight on the importance of targeting lack of healthcare coverage and other potential barriers to access to care in order to decrease racial differences in CHD death and foster health equity. Timely access to emergency care, including secondary prevention treatments, and effective preventive interventions could decrease the racial disparities in fatal CHD events. Insights from this dissertation can assist stakeholders in identifying opportunities to improve prevention policies in order to decrease CHD mortality for all Americans.
Table of Contents
CHAPTER 1: INTRODUCTION 1
1.1. Background and study motivation 1
1.2. Objective and Specific Aims 3
1.3. Data Sources 4
1.4. Public Health Importance 6
CHAPTER 2: BACKGROUND AND LITERATURE REVIEW 7
2.1. Definition and Epidemiology of Acute Coronary Syndromes 7
2.2. Symptoms and Initial Assessment of Acute Coronary Syndromes 8
2.3. Acute Coronary Syndromes as a Diagnostic Challenge 10
2.4. Racial differences in diagnosis and management of Acute Coronary Syndromes 11
2.5. Racial Differences in Out-of-Hospital Mortality of Coronary Heart Disease 13
2.6. Racial Differences in the Rates of Recurrent Myocardial Infarction 14
CHAPTER 3: METHODS 16
3.1. Study 1 16
3.1.1. Dataset - HCUP 16
3.1.2. Definition of Variables 17
3.2. Study 2 18
3.2.1. Dataset - ARIC cohort 18
3.2.2. Definition of Variables 19
3.3. Study 3 20
3.3.1. Dataset - ARIC surveillance 20
3.3.2. Definition of Variables 21
3.3.3. Modeling Approach 22
3.3.4. Mediation Analysis 22
CHAPTER 4: RACIAL DIFFERENCES IN HOSPITALIZATION RATES OF PATIENTS WHO RECEIVE A DIAGNOSIS OF ACUTE CORONARY SYNDROME IN THE EMERGENCY DEPARTMENT 23
4.1. Abstract 23
4.1.1. Background 23
4.1.2. Methods 24
4.1.3. Results 24
4.1.4. Conclusion 25
4.2. Introduction 25
4.3. Methods 26
4.3.1. Study population 26
4.3.2. Definition of race and outcomes 28
4.3.3. Definition of covariates 28
4.3.4. Statistical Analysis 29
4.4. Results 31
4.4.1. Characteristics of the study population 31
4.4.2. Racial differences in rates of being sent home after receiving a discharge code of ACS 31
4.5. Discussion 33
CHAPTER 5: RACIAL DIFFERENCES IN FATAL OUT-OF-HOSPITAL CORONARY HEART DISEASE AND THE ROLE OF INCOME: FINDINGS FROM THE ARIC COHORT STUDY (1987-2019) 47
5.1. Abstract 48
5.1.1. Background 48
5.1.2. Methods 48
5.1.3. Results 48
5.1.4. Conclusions 49
5.2. Introduction 49
5.3. Methods 51
5.3.1. Study 51
5.3.2. Statistical Analysis 53
5.4. Results 55
5.4.1. Characteristics of participants at baseline 55
5.4.2. Racial differences in fatal and nonfatal incident CHD 55
5.4.3. Racial differences in out-of-hospital and in-hospital fatal incident CHD 56
5.5. Discussion 57
5.6. Acknowledgments 60
5.7. Sources of Funding 60
CHAPTER 6: RACIAL DIFFERENCES IN RECURRENT ACUTE MYOCARDIAL INFARCTION IN THE COMMUNITY: FINDINGS FROM THE ARIC COMMUNITY SURVEILLANCE STUDY FROM 2005 TO 2014 75
6.1. Abstract 76
6.2. Introduction 77
6.3. Methods 78
6.4. Results 81
6.5. Discussion 83
6.6. Acknowledgments 87
6.7. Sources of Funding 87
CHAPTER 7: SUMMARY AND FUTURE DIRECTIONS 93
7.1. Summary 93
7.2. Strengths 95
7.3. Limitations 96
7.4. Public Health Impact and Future Directions 97
REFERENCES 99
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