Race Matters: Disparities in Patients Presenting to the Emergency Department With Potential Acute Coronary Syndrome

Purpose: The purpose of this study was to examine disparities in clinical presentation, treatment, and patient-reported outcomes between non-Hispanic Blacks and non-Hispanic Whites presenting to the emergency department (ED) with potential ACS. The complex relationship between race and health disparities in coronary heart disease (CHD) remains poorly understood. The presence of health disparities suggest that disadvantage, resulting in disease, is unjust and avoidable. Patterns of health disparities across the globe have been consistent; individuals with fewer resources have worse health outcomes and individuals with fewer resources are disproportionately those of color. It has been well documented that Blacks have higher numbers of risk factors for acute coronary syndrome (ACS), such as hypertension, diabetes, and smoking, compared to Whites. In addition, Blacks have among the highest incidence of hypertension (44%) in the world.

Methods: Patients in this sample (n=663) were part of a larger National Institute of Nursing Research sponsored ACS study. Individuals presenting to the ED with symptoms triggering a cardiac evaluation, ≥21 years old, and fluent in English or Spanish were eligible. Patients were excluded if they had an exacerbation of heart failure, were transferred from a hemodialysis facility, were referred for evaluation of a dysrhythmia, or had cognitive impairment. The validated ACS Symptom Checklist, ACS Patient Information Questionnaire, Froelicher’s Health Services Utilization Questionnaire-Revised, and a medical record review form were used to measure clinical presentation, treatment, and patient-reported outcome variables at baseline and one and six months following discharge.

Results: Participants included 116 non-Hispanic Black patients (17.5%) and 547 non-Hispanic White patients (82.5%). There were no differences between Blacks and Whites in the percentage of those ruled-in versus ruled-out for ACS, type of ACS (unstable angina, non-ST elevation myocardial infarction, or ST elevation myocardial infarction), or sex. More than 80% of the sample had health insurance and rates did not differ by race (Black=80.4% & White=86.6%, p=0.26). Blacks with confirmed ACS were younger; had lower income; less education; more risk factors; more symptoms, and longer prehospital delay at presentation compared to Whites. Blacks experiencing palpitations, unusual fatigue, and chest pain were more than 3 times as likely as Whites to have ACS confirmed. Blacks with ACS had more clinic visits and more symptoms one month following discharge.

Conclusion: Significant disparities in socioeconomic factors, risk factors, prehospital delay times, symptoms, and healthcare utilization for Blacks and Whites following presentation to the ED for symptoms suggestive of ACS persist despite a decrease in mortality rates and a plethora of prior data on racial disparities. For every disparity identified in this study, Blacks were at a disadvantage. Identification of these racial disparities may open new lines of inquiry focused on design and testing of patient-centered interventions for those with a history of or who are at risk for ACS. Further research on differences in clinical presentation and outcomes between Blacks and Whites with ACS is warranted to reduce disparities.