Differences in Short-Term Versus Long-Term Outcomes of Older Black Versus White Patients With Myocardial Infarction

Abstract

Background— 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. Methods and Results— 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. Conclusions— 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.