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Effect of Race on the Presentation and Management of Patients with Acute Chest Pain

Paula A. Johnson, MD, MPH; Thomas H. Lee, MD, MSc; E. Francis Cook, ScD; Gregory W. Rouan, MD; and Lee Goldman, MD
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; University of Cincinnati Hospital, Cincinnati, Ohio. Requests for Reprints: Lee Goldman, MD, Division of Clinical Epidemiology, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Grant Support: In part by grant R01HS06452 from the Agency for Health Care Policy and Research and grant HS-5927 from the National Center for Health Services Research. Dr. Johnson is the recipient of a Clinician-Scientist Award (91004160) from the American Heart Association. Dr. Lee is the recipient of an Established Investigator Award (900119) from the American Heart Association. Dr. Rouan was a Teaching and Research Scholar of the American College of Physicians during the time of the study.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;118(8):593-601. doi:10.7326/0003-4819-118-8-199304150-00004
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Objective: To compare racial differences in clinical presentation, natural history, and access to medical care and procedures among emergency-department patients with acute chest pain.

Design: Prospective follow-up study of consecutive patients coming to the emergency department because of acute chest pain.

Setting: Two university medical centers.

Patients: A total of 3031 patients who were 30 years or older and who came to the emergency department with acute chest pain from 1984 to 1986.

Main Results: African-Americans tended to have slightly, but not always significantly, lower rates of acute myocardial infarction, acute ischemic heart disease, and major complications, after adjusting for presenting symptoms and signs; the adjusted odds ratios for African-Americans were as follows: 0.77 (95% CI, 0.54 to 1.1) for acute myocardial infarction, 0.75 (CI, 0.59 to 0.95) for ischemic heart disease, and 0.79 (CI, 0.45 to 1.4) for death or major complications. Clinical factors classically associated with acute myocardial infarction were equally predictive in African-Americans and whites. After adjustments were made for multiple clinical factors, a lower proportion of African-Americans were admitted to the hospital (odds ratio, 0.69; CI, 0.56 to 0.84), and, once admitted, were somewhat less likely to be triaged to the coronary care unit (odds ratio, 0.81; CI, 0.65 to 1.0). In adjusted analyses, African-Americans were as likely to undergo cardiac catheterization as whites (odds ratio, 0.86; CI, 0.64 to 1.2) but were less likely to undergo coronary artery bypass procedures once severity of coronary disease was included in the analysis (odds ratio, 0.24; CI, 0.08 to 0.71).

Conclusion: African-Americans and whites had a similar presentation and natural history of acute myocardial infarction and, after adjusting for probability of clinical events, similar access to most medical care and cardiac procedures. However, the rate of coronary artery bypass procedures was much lower among African-Americans than among whites. Reasons for this difference should be studied.


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Figure 1.
Derivation of the study population of 3031 patients from the 4173 patients who came to the emergency department with acute chest pain.
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Figure 2.
Odds ratios for undergoing coronary artery bypass surgery in African-Americans when compared with whites.

Patients were stratified by severity of coronary artery disease. Although the 95% CIs include 1.0 for one- and three-vessel and left main coronary artery disease, the odds ratio is less than 1.0 when calculated using the Mantel-Haenszel summary statistic.

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