A study, published ahead of print in the American Journal of Cardiology, has found that black patients undergo aortic valve replacement for aortic stenosis significantly less frequently than white patients and also found that black patients decline surgery more often than white patients.
Michael Yeung (Division of Cardiology, University of North Carolina, Chapel Hill, USA) and others commented that studies have shown that black patients undergo interventions for acute myocardial infarction less frequently than do white patients.
Furthermore, as reported in Cardiovascular News, a recent study found that black and Hispanic patients have worse outcomes following percutaneous coronary intervention (PCI) than white patients. Yeung et al commented: “However, the role of race in forgoing aortic valve replacement has not been previously investigated. We conducted a study with the following aims: to determine if African Americans with severe aortic stenosis underwent aortic valve replacement less frequently than European Americans with severe aortic stenosis and to identify the reasons for this disparity if present.”
Using data from a tertiary referral centre, Yeung et al identified patients with severe aortic stenosis (on echocardiogram) and also identified the percentage of patients who were African American and the percentage of patients who were European American. They excluded patients who were neither African American nor European American. The authors also assessed how patients were severe aortic stenosis were managed and reviewed, in patients who were not treated with surgery, the reasons for non-surgical management.
Of 880 patients with severe aortic stenosis and known treatment status, 791 (90%) were European American and 89 were African American (10%). Although the rates of symptomatic aortic stenosis were similar between racial groups, European Americans complained more frequently of dyspnoea and African Americans had evidence of worse disease severity on echocardiogram. Overall, 51% of patients with severe aortic stenosis underwent aortic valve replacement. However, significantly fewer African Americans underwent surgery than European Americans (39% vs. 53%, respectively; p=0.019).
Yeung et al also found that compared with patients with severe aortic stenosis who did not undergo surgery, patients who underwent aortic valve replacement had significantly better survival rates at both one and three years. Among those who underwent surgery, there were no significant differences in survival rates following surgery between African Americans and European Americans. The authors noted that this finding indicates that “aortic valve replacement is similarly effective in both groups”.
The reasons for not undergoing surgery (ranging from advanced age to lack of symptoms) were mostly similar between groups, but African Americans more frequently declined surgery than did European Americans. Yeung et al reported that as previous studies have suggested that cultural preferences influence the decision-making process in cardiac surgery, cultural preferences may explain why more African Americans declined surgery. They added: “Another explanation for our findings may include poor communication by practitioners, resulting in misunderstanding of the disease process by the patient.” According to the authors, education and individual counselling to promote awareness and a better understanding of the decision-making process “may level this inequality treatment.”
While the number of patients who had medical insurance in each group was identical, more European Americans had private medical insurance than had African Americans. Yeung et al said: “It is unclear whether possessing private insurance influenced the decision-making process to undergo aortic valve replacement; however, having private insurance may imply that socioecoonomic status does play a role in the decision-making process, independent of the actual cost and ability to pay for the procedure and postdischarge care.”
Study author Alan Zajarias, Division of Cardiovascular Diseases, Washington University in St Louis School of Medicine, St Louis, USA, told Cardiovascular News: “Socioeconomic status may influence the ability of patients to fully understand a disease process, treatment options and their implications. This may be one of the reasons leading to the treatment. differences seen in the study.”