A new study co-authored by heart experts from Emory and other academic medical centers found significant racial and ethnic disparities in outcomes for patients who experience the most severe kind of heart attack, ST elevation myocardial infarction or STEMI.
For the paper, which was published on July 17 in Circulation, researchers looked at data from 2015-2021 on 178,062 STEMI patients enrolled in the American Heart Association (AHA) “Get with The Guidelines” coronary artery disease registry. Patients were broken into the racial and ethnic groups of non-Hispanic White, Hispanic White and Black/African American.
Through the multi-year, nationwide examination, they found that Black/African American and Hispanic White patients had lower odds of meeting the standard recommended time frame of diagnosis to treatment than non-Hispanic White patients. Researchers also found that Black and Hispanic patients had lower odds of receiving a prehospital electrocardiogram (ECG) or meeting the recommended targets for other processes and procedures associated with STEMI care.
Emory cardiologist and epidemiologist Abhinav Goyal, MD, was co-author on the recent paper in Circulation.
STEMI is what happens when the major artery feeding into the heart gets blocked by plaque buildup, impacting blood flow and leading to clotting, which then deprives the heart muscle of oxygen, causing it to swiftly deteriorate.
Because STEMI begins and escalates so quickly, and because it requires mechanical intervention from a specially trained medical team, it’s critical that patients arrive in a fully equipped Cath lab as quickly as possible, not only to save their life but also to avoid serious consequences later. Even with rapid treatment, an estimated 30 percent or more of STEMI patients die within five years.
“The time actually should start when the paramedics arrive at the patient's side in the field, in the pre-hospital setting,” said the paper’s corresponding author Abhinav Goyal, MD, an Emory cardiologist and epidemiologist who oversees all quality-related initiatives in the Emory Heart and Vascular Center. “We now have systems of care where EMS colleagues arrive at the patient's side, ascertain the patient having heart attack symptoms, perform an ECG on the spot, and then they can radio into the hospital, so they’re prepared.”
STEMI patients need to be taken to a cardiac Cath lab where physicians can put a catheter into the arteries and work to open the blockage. Unfortunately, many healthcare centers in the U.S., particularly in remote or rural areas, don't have that capability 24 hours a day, seven days a week, which means that patients may need to receive clot-busting medication temporarily until they can get to the right facility.
As part of the study, researchers looked at in-hospital death rates once patients arrived and found that instances of death from STEMI were higher among Hispanic White women than they were with non-Hispanic White women.
Notably, racial and ethnic disparities were still present even when the research team adjusted their findings to account for age, other serious health conditions (like diabetes), whether patients had insurance, and socioeconomic status.
Lead author Asishana Osho, MD, is a cardiac surgeon at Massachusetts General Hospital and assistant professor of surgery at Harvard Medical School.
Goyal agrees. “The elephant in the room is the question of whether there are conscious or subconscious biases toward Black and Hispanic patients that are leading towards some of these differences in care,” he said. “That is certainly an underlying factor that could exist.”
It’s not the first time that questions have been broached around health disparities and other registries around procedural areas like heart catheterization and heart attacks. What’s new here is that this study looked at heart attack care beyond just the hospital setting – something which Goyal said was pitched to him by another co-author on the study, Marcelo Fernandez, a recently graduated Emory cardiology fellow.
“We extended our search for disparities of care to include a cadre of pre-hospital metrics which had not been thoroughly looked at prior to this paper,” Goyal said.
Similarly, Osho said he had been discussing this topic with colleagues in Boston for a while, and “proposed this question after discovering that newer system of care metrics in STEMI care that included pre-hospital time points had not been rigorously investigated for ethnicity-based disparities.”
AHA’s Get With The Guidelines coronary artery disease registry was an ideal choice for the study because of its reach: it enrolls patients admitted with STEMI to one of over 700 participating hospitals across the United States.
One striking aspect of the study’s findings, Goyal points out, is that 60% of patients with STEMI called or had someone call 911 for them, while 40% of patients didn’t call 911, and instead drove or walked to the hospital.
There are numerous factors for why patients opt out of 911. Sometimes it has to do with not recognizing how serious a heart attack can be, and what the signs and symptoms are – particularly in women, where symptoms may not be the “textbook” definition of excruciating chest pain, but rather dizziness or nausea.
There’s also the concern about the financial burden of an ambulance ride, which can sometimes cost thousands of dollars even with health insurance. There’s also the potential for mistrust or skepticism around calling 911, out of safety concerns.
Another important consideration is that all this data was collected before the pandemic, which may mean that these already-existing disparities are now even more pronounced. In the wake of Covid-19, when all healthcare systems were strained – emergency rooms and EMS especially – there has been a noticeable backslide in the amount of time from contact to Cath lab, Goyal said.
“Now, we’re just kind of reemerging and we're realizing we lost some ground and that if you take the foot off the gas, you're going to get stagnancy or even a little bit of some regression,” he said.
As chair of the regional system of care, Goyal spent a decade, from 2007 to 2017, helping with the development of Atlanta's STEMI system of care. They have 17 or 18 participating hospitals in Atlanta and over 30 or 40 participating EMS companies. Now, as healthcare slides back into a more normal routine, Goyal said that paying attention to these racial and ethnic disparities is an important part of that work to rebuild.
“Even if you have longstanding systems of care, you can't take for granted that everyone, all segments of the population, women, men, racial and ethnic groups, that they're all benefiting equally from these STEMI systems of care. There's still gaps that we need to bridge,” he said.