Suboptimal Care for Women With CAD Linked to Higher Long-Term Mortality


Data from a US registry hint that there may well be ways to at least partially erase the sex disparity between women and men hospitalized for cardiac conditions. After they leave the hospital, women face higher 3-year mortality, but more than two-thirds of that difference seems to stem from “suboptimal care” at the time of discharge, researchers report.

The Take Home: Suboptimal Care for Women With CAD Linked to Higher Long-Term Mortality

“About 69% of the mortality disparity could in theory be reduced or eliminated if we just provided optimal, guideline-based care to women at a similar rate as we do to men,” senior author Deepak L. Bhatt, MD, of Brigham and Women’s Hospital (Boston, MA), told TCTMD. He pointed out that the analysis took into account that some patients might have a legitimate contraindication to an aspect of recommended care.

Along with lead author Shanshan Li, MD, ScD, of the Harvard T.H. Chan School of Public Health (Boston, MA), Bhatt and colleagues used data from the Get With the Guidelines-Coronary Artery Disease Registry to perform a cohort study of 49,358 patients ages 65 years and older who were admitted to 366 US hospitals between 2003 and 2009. Reasons for admission spanned the spectrum from chronic stable angina and ischemic heart disease to unstable angina and acute MI.

The researchers sought to understand whether optimal quality of care—including aspirin within 24 hours and at hospital discharge, beta-blocker at discharge, ACE inhibitor/ARB at discharge for patients with low ejection fraction, smoking cessation counseling, and lipid-lowering medications—might serve as a mediator of outcomes. Their findings were published online earlier this week in Circulation: Cardiovascular Quality and Outcomes.

Women were less likely to receive optimal care than were men (OR 0.92; 95% CI 0.88-0.95). Among patients given suboptimal care, women had higher 3-year mortality than did their male counterparts (OR 1.25; 95% CI 1.00-1.05). The interplay between sex, quality of care, and mortality risk was significant (P for interaction = .04).

“Approximately 69% of the sex disparity may potentially be reduced by providing optimal quality of care to women,” the authors assert.

Notably, the quality of care did not differ among racial/ethnic groups or geographic regions. While African-American patients were one-third more likely than white patients to die within 3 years (OR 1.33; 95% 1.21-1.46), this disparity was not ameliorated for those receiving optimal care.

Good News and Bad News

Acknowledging that the findings for women could be seen as “the glass is half full or half empty,” Bhatt said, “I actually interpret it as good news because it means that whatever mortality gaps there are in women versus men, at least for coronary artery disease, a good chunk of it can be reduced. . . . It would take effort, of course. It’s not an easy thing to always deliver optimal guideline-based care, but it’s not as if it’s an unknown biological mechanism that has yet to be uncovered.”

That being said, he added, there could well be some biological differences that merit further study.

The persistent mortality risk seen for African-American patients “even if delivery of care is excellent,” Bhatt said, “is not such an optimistic message.”

Delivery of care does vary by race and by socioeconomic status, he noted. “But even if those [disparities in care] were magically eliminated, our study suggests that African-American patients would still have higher mortality. That is concerning, and that means there are other factors. Not necessarily just fundamental biological factors; there could be other things that we couldn’t totally account for, like access to healthcare or [a patient’s] socioeconomic status, but it is a bit more sobering message. It argues that there isn’t an as apparent or easy a fix in African-Americans.


Source: 
Li S, Fonarow GC, Mukamal KJ, et al. Sex and race/ethnicity related disparities in care and outcomes after hospitalization for coronary artery disease among older adults. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.

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Disclosures
  • The study was supported by an American Heart Association (AHA) Get With The Guidelines young investigator grant.
  • Li reports no relevant conflicts of interest.
  • Bhatt reports serving on the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; on the board of directors of Boston VA Research Institute, Society of Cardiovascular Patient Care; as chair of the AHA Quality Oversight Committee; on the data monitoring committees of Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; as site co-investigator of Biotronik, Boston Scientific, and St. Jude Medical; and as a trustee of the American College of Cardiology (ACC). He also reports receiving honoraria from the ACC (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), and WebMD (CME steering committees); research funding from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; and royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease). He additionally reports being involved in unfunded research with FlowCo, PLx Pharma, and Takeda.

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