Advertisement

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales

  • Author Footnotes
    ‡ These authors contributed equally to this work.
    Mohamed Dafaalla
    Footnotes
    ‡ These authors contributed equally to this work.
    Affiliations
    Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom

    Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
    Search for articles by this author
  • Author Footnotes
    ‡ These authors contributed equally to this work.
    Muhammad Rashid
    Footnotes
    ‡ These authors contributed equally to this work.
    Affiliations
    Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom

    Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
    Search for articles by this author
  • Rachel M. Bond
    Affiliations
    Women’s Heart Health, Dignity Health, Gilbert, Arizona, USA

    Internal Medicine, Creighton University School of Medicine, Chandler, Arizona, USA
    Search for articles by this author
  • Triston Smith
    Affiliations
    Department of Cardiology, Trinity Health System, Steubenville, Ohio, USA
    Search for articles by this author
  • Purvi Parwani
    Affiliations
    Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, California, USA
    Search for articles by this author
  • Ritu Thamman
    Affiliations
    University of Pittsburgh, Pittsburgh, Pennsylvania, USA
    Search for articles by this author
  • Saadiq M. Moledina
    Affiliations
    Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom

    Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
    Search for articles by this author
  • Michelle M. Graham
    Affiliations
    Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

    Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
    Search for articles by this author
  • Mamas A. Mamas
    Correspondence
    Corresponding author: Professor Mamas A. Mamas, Keele Cardiovascular Research Group, Centre of Prognosis Research, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom. Tel.: +441782 715444.
    Affiliations
    Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom

    Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom

    Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Author Footnotes
    ‡ These authors contributed equally to this work.
Open AccessPublished:October 01, 2021DOI:https://doi.org/10.1016/j.cjco.2021.09.026

      Abstract

      Background

      Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown.

      Methods

      Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy.

      Results

      From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group.

      Conclusions

      BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

      Résumé

      Introduction

      Les études sur les inégalités raciales en matière de soins aux patients admis en raison d’un arrêt cardiaque hors de l’hôpital (ACHO) dans le cadre d’un infarctus aigu du myocarde (IAM) ont montré des résultats contradictoires. On ignore si ces différences en matière de soins existent dans le système de soins de santé universel de l’Angleterre.

      Méthodes

      Les patients admis en raison d’un diagnostic d’IAM et d’ACHO entre 2010 et 2017 du Myocardial Ischaemia National Audit Project (MINAP) ont fait l’objet de l’étude. Nous avons réparti tous les patients selon l’origine ethnique dans le groupe BAME (de l’anglais Black, Asian and minority ethnic, c.-à-d. Noirs, Asiatiques ou d’une minorité ethnique) vs le groupe des Blancs. Nous avons utilisé les modèles multivariés de régression logistique pour évaluer les prédicteurs des résultats cliniques et la stratégie de traitement.

      Résultats

      Parmi les 14 287 patients admis en raison d’un IAM compliqué par l’ACHO, les patients du BAME constituaient une minorité de patients (1 185 [8,3 %]) par rapport au groupe des Blancs (13 102 [91,7 %]). Les patients du groupe BAME étaient plus jeunes (âge médian [écart interquartile]), 58 [50-70] ans que le groupe des Blancs, 65 [55-74] ans). Le choc cardiogénique (groupe BAME, 33 %; groupe des Blancs, 20,7 %; P < 0,001) et l’insuffisance ventriculaire gauche grave (groupe BAME, 21 %; groupe des Blancs, 16,5 %; P < 0,003) étaient plus fréquents au sein des patients du BAME. Il était plus probable que les patients du BAME soient vus par un cardiologue (groupe du BAME, 95,9 %; groupe des Blancs, 92,5 %; P < 0,001) et qu’ils passent une angiographie coronarienne que le groupe des Blancs (ratio d’incidence approché [RIA] 1,5, intervalle de confiance [IC] à 95 % 1,2-1,88). Le groupe BAME avait une mortalité intrahospitalière (RIA 1,26, IC à 95 % 1,04-1,52) et une récidive d’infarctus (RIA 1,52, IC à 95 % 1,06-2,18) plus élevées que le groupe des Blancs.

      Conclusions

      Il était plus probable que les patients du BAME soient vus par un cardiologue et qu’ils passent une angiographie coronarienne que les patients blancs. Malgré cette différence, la mortalité intrahospitalière des patients du BAME, particulièrement de la population asiatique, était significativement plus élevée.

      Graphical abstract

      Out-of-hospital cardiac arrest (OHCA) is a major cause of cardiovascular mortality.
      • Forslund A.-S.
      • Söderberg S.
      • Jansson J.-H.
      • Lundblad D.
      Trends in incidence and outcome of out-of-hospital cardiac arrest among people with validated myocardial infarction.
      ,
      • Nichol G.
      • Thomas E.
      • Callaway C.W.
      • et al.
      Regional variation in out-of-hospital cardiac arrest incidence and outcome.
      Approximately 275,000 persons experience OHCA in Europe annually, with only 29,000 surviving to hospital discharge.
      • Atwood C.
      • Eisenberg M.S.
      • Herlitz J.
      • Rea T.D.
      Incidence of EMS-treated out-of-hospital cardiac arrest in Europe.
      Ethnicity is an important factor in determining an individual’s place of residence, socioeconomic status, and access to cardiopulmonary resuscitation in their community, factors known to be associated with significant variation in the response to and outcomes of OHCA.
      • Sasson C.
      • Magid D.J.
      • Chan P.
      • et al.
      Association of neighborhood characteristics with bystander-initiated CPR.
      ,
      • Agerström J.
      • Carlsson M.
      • Bremer A.
      • et al.
      Discriminatory cardiac arrest care? Patients with low socioeconomic status receive delayed cardiopulmonary resuscitation and are less likely to survive an in-hospital cardiac arrest.
      Although many studies have assessed racial differences in the care of OHCA complicated by an acute myocardial infarction (AMI), results have been inconsistent.
      • Shah K.S.V.
      • Shah A.S.V.
      • Bhopal R.
      Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse.
      • Chen J.
      • Rathore S.S.
      • Radford M.J.
      • Wang Y.
      • Krumholz H.M.
      Racial differences in the use of cardiac catheterization after acute myocardial infarction.
      • Sayegh A.J.
      • Swor R.
      • Chu K.H.
      • et al.
      Does race or socioeconomic status predict adverse outcome after out of hospital cardiac arrest: a multi-center study.
      • Galea S.
      • Blaney S.
      • Nandi A.
      • et al.
      Explaining racial disparities in incidence of and survival from out-of-hospital cardiac arrest.
      Some studies suggest that clinical outcomes are worse among ethnic minorities, compared with the White population.
      • Shah K.S.V.
      • Shah A.S.V.
      • Bhopal R.
      Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse.
      ,
      • Chen J.
      • Rathore S.S.
      • Radford M.J.
      • Wang Y.
      • Krumholz H.M.
      Racial differences in the use of cardiac catheterization after acute myocardial infarction.
      ,
      • Cowie M.R.
      • Fahrenbruch C.E.
      • Cobb L.A.
      • Hallstrom A.P.
      Out-of-hospital cardiac arrest: racial differences in outcome in Seattle.
      These studies attribute these racial disparities to various factors that affect community response, such as socioeconomic status, lack of awareness in recognizing symptoms, delay in seeking early medical help, and implicit bias from the treating physicians.
      • Sasson C.
      • Magid D.J.
      • Chan P.
      • et al.
      Association of neighborhood characteristics with bystander-initiated CPR.
      ,
      • Agerström J.
      • Carlsson M.
      • Bremer A.
      • et al.
      Discriminatory cardiac arrest care? Patients with low socioeconomic status receive delayed cardiopulmonary resuscitation and are less likely to survive an in-hospital cardiac arrest.
      For instance, a meta-analysis of racial disparities in outcomes of OHCA complicating AMI in the US showed that Black populations have worse outcomes than White populations.
      • Shah K.S.V.
      • Shah A.S.V.
      • Bhopal R.
      Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse.
      Most studies of racial disparities in AMI with OHCA have used data from the US; studies examining OHCA characteristics and survival in Europe and the United Kingdom
      • Shah K.S.V.
      • Shah A.S.V.
      • Bhopal R.
      Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse.
      are lacking. Data from the United Kingdom can give additional insights on the impact of racial disparities, because of differences in its population structure, compared with that in the US, and the availability of universal healthcare through the National Health Service (NHS). The NHS is a universal public sector system that provides universal access to health services to the whole population, independent of their socioeconomic status. In contrast, access to US healthcare systems and the quality of care received depend, to a greater extent, on patients’ socioeconomic status and medical insurance coverage. This means that individuals in the lower socioeconomic strata of society are unable to afford healthcare expenses, despite large governmental expenditure, placing the Black population at a disproportional disadvantage.
      • Kerr D.J.
      • Scott M.
      British lessons on health care reform.
      ,

      Moledina SM, Shoaib A, Weston C, et al. Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study. Eur Heart J Qual Care Clin Outcomes April 21, 2021 [online ahead of print]; https://doi.org/10.1093/ehjqcco/qcab030.

      We used the Myocardial Ischaemia National Audit Project (MINAP), a national registry of AMI hospitalizations in England and Wales, to study the impact of patients’ ethnicity on the processes of care and the clinical outcomes of patients admitted with AMI complicated by OHCA between 2010 and 2017.

      Methods

      Study design

      The MINAP is a national cardiac audit that collects information relating to the presenting profile and clinical care of patients hospitalized with a diagnosis of AMI in England.
      • Birkhead J.S.
      • Weston C.F.M.
      • Chen R.
      Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP).
      • Rashid M.
      • Curzen N.
      • Kinnaird T.
      • et al.
      Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: nationwide analysis from MINAP.
      • Rashid M.
      • Kontopantelis E.
      • Kinnaird T.
      • et al.
      Association between hospital cardiac catheter laboratory status, use of an invasive strategy, and outcomes after NSTEMI.
      The data collected are utilized for auditing quality of care and public reporting of AMI patients and also provide a resource for academic research.

      Moledina SM, Shoaib A, Weston C, et al. Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study. Eur Heart J Qual Care Clin Outcomes April 21, 2021 [online ahead of print]; https://doi.org/10.1093/ehjqcco/qcab030.

      ,
      • Rashid M.
      • Curzen N.
      • Kinnaird T.
      • et al.
      Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: nationwide analysis from MINAP.
      ,
      • Herrett E.
      • Smeeth L.
      • Walker L.
      • Weston C.
      MINAP Academic Group
      The Myocardial Ischaemia National Audit Project (MINAP).
      The database contains information about patient demographics, admission time and method, cardiovascular comorbidities, clinical characteristics, relevant investigations, in-hospital pharmacologic and interventional treatments, in-hospital outcomes, and discharge treatments.
      • Rashid M.
      • Kontopantelis E.
      • Kinnaird T.
      • et al.
      Association between hospital cardiac catheter laboratory status, use of an invasive strategy, and outcomes after NSTEMI.
      ,
      • Wu J.
      • Mamas M.
      • Rashid M.
      • et al.
      Patient response, treatments, and mortality for acute myocardial infarction during the COVID-19 pandemic.

      Study population

      The cohort for this study included all patients aged > 18 years admitted with a final diagnosis of AMI (either ST-segment elevation myocardial infarction [STEMI] or non-STEMI [NSTEMI]) and OHCA between January 1, 2010 and March 31, 2017. The discharge diagnosis of AMI was established by the treating clinician according to the presenting history, clinical examination, and results of inpatient investigations based on the consensus document of the Joint European Society of Cardiology and the American College of Cardiology.
      • Alpert J.S.
      • Thygesen K.
      • Antman E.
      • Bassand J.P.
      Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.
      The total number of patients diagnosed with AMI was 664,740. Of those, the number of patients who did not present with OHCA was 511,329. Patients with missing data, including ST elevation on presentation (41,124 patients), ethnicity (55,153 patients), cardiac arrest site (22,140 patients), and in-hospital mortality information (20,707 patients) were excluded from the analysis. The final number of patients included in the cohort was 14,287 (Supplemental Fig. S1).
      In the MINAP, a patient’s ethnic group was defined based on patient self- reporting using race categories that are used nationally in this and other national electronic health records. All patients were stratified into 1 of 2 ethnicity groups: a Black, Asian, or minority ethnicity (BAME) group vs a White group. The BAME group included those whose race was recorded as Black (including Caribbean, African, Black British, and any other Black background), Asian (including Indian, Pakistani, Bangladeshi, Asian British, and any other Asian Background, but excluding Chinese), or other non-White ethnicity (including Chinese). We collected detailed information on patient characteristics, clinical presentations, comorbidities, and discharge pharmacology. The outcomes of interest were in-hospital mortality, re-infarction, major bleeding, and utilization of coronary angiography and percutaneous coronary intervention (PCI). In-hospital major bleeding was defined as a composite of intracranial bleeding, retroperitoneal bleeding, and any bleeding with a > 3 g/L fall in hemoglobin concentration.

      Ethical approval

      Ethical approval was not required for this study, under current arrangements by the NHS research governance body, because the MINAP database was collected and used for research purposes without informed patient consent by the National Institute for Cardiovascular Outcomes Research under section 251 of the National Health Service Act of 2006.
      National Archives
      National Health Service Act 2006.

      Data quality

      The MINAP tackles oversight by providing guidance and technical advice for staff who are entering data, via a dedicated helpdesk, and consistently using error-checking routines in a MINAP data application. The completeness of 20 key fields is closely monitored and is generally above 95%. These fields include NHS number, discharge diagnosis, hospital mortality, and secondary prevention medication prescribed at discharge. A data validation exercise is done annually and requires every hospital to re-enter 20 data items from the medical records of 20 randomly selected patients, using a specially designed data validation tool.
      • Herrett E.
      • Smeeth L.
      • Walker L.
      • Weston C.
      MINAP Academic Group
      The Myocardial Ischaemia National Audit Project (MINAP).

      Statistical analysis

      We described the baseline characteristics as number and percentage for categorical variables, and as median and interquartile range for continuous variables. The χ2 test and t-test were used to test for statistical significance between categorical and continuous variables, respectively. The Kruskal–Wallis test was used for skewed data. We used multiple imputation techniques with chained equations to account for the missing data. Age, sex, ethnicity, clinical diagnosis, and in-hospital mortality were registered as regular variables in the imputations model, and all other variables, including body mass index, seen by cardiologists, left ventricular systolic function, previous PCI, coronary artery bypass graft, heart failure, hypercholesterolemia, angina, cerebrovascular disease, peripheral vascular disease, creatinine levels, diabetes, hypertension, smoking status, asthma or chronic obstructive pulmonary disease, family history of coronary disease, in-hospital use of low-molecular-weight heparin, warfarin, loop diuretics, oral beta-blockers, and angiotensin-converting enzyme inhibitor were imputed (Supplemental Table S1). The variable selection in the model was based on previous studies using the MINAP registry, and prior clinical knowledge.
      • Rashid M.
      • Curzen N.
      • Kinnaird T.
      • et al.
      Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: nationwide analysis from MINAP.
      Using these models, 10 imputed datasets were generated that were used to perform all the analyses. Multivariable logistic regression models were used to study the association between ethnicity and clinical outcomes. We undertook a sensitivity analysis to compare and contrast clinical characteristics, management strategies, and clinical outcomes among the Black population, the Asian population, and other non-White ethnic minorities (Other), using the White group as a reference. All models included the same variables used in the multiple imputation models, as well as the year of admission. Estimates in the form of odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported. Statistical significance was considered to be indicated by an alpha of 0.05 in all the 2-sided tests used. Stata, version 14.1 (StataCorp LLC, College Station, TX), was used to perform all the analyses.

      Results

      Patients’ characteristics

      Of 14,287 patients admitted with AMI complicated by OHCA, the BAME patients constituted a minority (8.3%). The BAME patients were younger (BAME group median age [interquartile range] 58 [50-70] years; White group median age [interquartile range] 65 [55-74] years), with a lower proportion of women (BAME group, 18.0%; White group, 23.2%; P < 0.001). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. Cardiometabolic risk factors were more prevalent in BAME patients than White patients, particularly diabetes (BAME group, 31%; White group, 13%; P < 0.001), hypertension (BAME group, 48%; White group, 41%; P < 0.001), hypercholesterolemia (BAME group, 35%; White group, 26%; P < 0.001), heart failure (BAME group, 6.5%; White group, 4.6%; P = 0.008), and chronic kidney disease (BAME group, 5.2%; White group, 3.8%; P = 0.024). Table 1 shows the patients' characteristics and the clinical presentation of AMI patients with OHCA. The proportion of AMI patients with OHCA from the BAME group tripled, from around 4% in 2010 to 12% in 2017 (Fig. 1).
      Table 1Characteristics and clinical presentation of acute myocardial infarction (MI) patients with out-of-hospital cardiac arrest
      CharacteristicWhiteBAMEP
      n13,1021185
      Age, y65.0 (55.0, 74.0)58.0 (50.0, 70.0)< 0.001
      Women3045 (23.2)213 (18.0)< 0.001
      BMI26.9 (24.0, 30.2)26.3 (23.2, 29.5)0.35
      Clinical diagnosis
       STEMI10027 (76.5)973 (82.1)< 0.001
       NSTEMI/UA3075 (23.5)212 (17.9)
      Site of infarction
       Anterior4298 (48.2)493 (55.5)< 0.001
       Inferior3074 (34.4)246 (27.7)
       Posterior492 (5.5)38 (4.3)
       Lateral450 (5.0)48 (5.4)
       Undetermined610 (6.8)63 (7.1)
      Killip class
       I5357 (62.4)434 (49.9)< 0.001
       II1020 (11.9)97 (11.2)
       III427 (5.0)44 (5.1)
       IV (shock)1781 (20.7)294 (33.8)
      LV function
       Good
      LV function assessment is based on ejection fraction measurement from transthoracic echocardiogram.
      2720 (26.2)248 (25.7)0.003
       Moderate3315 (31.9)296 (30.7)
       Poor1716 (16.5)203 (21.1)
       Creatinine, mmol/L94.0 (78.0, 116.0)97.0 (81.0, 126.0)0.11
       Elevated cardiac enzymes11176 (97.1)939 (93.2)< 0.001
       Angina pectoris1636 (14.4)162 (15.4)0.41
       Previous MI1982 (17.3)199 (18.8)0.22
       Diabetes1614 (13.4)334 (30.8)< 0.001
       Hypertension4649 (40.6)511 (48.2)< 0.001
       Hypercholesterolemia2934 (26.1)365 (35.1)< 0.001
      Smoking
       Never3989 (37.4)527 (53.6)< 0.001
       Ex-smoker2613 (24.5)145 (14.7)
       Smoker4056 (38.1)312 (31.7)
       FH of coronary artery disease2226 (23.8)167 (18.4)< 0.001
       Previous PCI883 (7.7)134 (12.7)< 0.001
       Previous CABG581 (5.1)50 (4.7)0.64
       Stroke713 (6.3)75 (7.1)0.28
       Peripheral vascular disease453 (4.0)20 (1.9)< 0.001
       Heart failure525 (4.6)68 (6.5)0.008
       Chronic kidney disease429 (3.8)54 (5.2)0.024
       Asthma/COPD1378 (12.1)94 (8.9)0.002
      BAME, Black, Asian, or minority ethnicity; BMI, body mass index; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; FH, family history; LV, left ventricle; NSTEMI, non-STEMI; PCI, percutaneous coronary intervention; STEMI, ST elevation myocardial infarction; UA, unstable angina.
      LV function assessment is based on ejection fraction measurement from transthoracic echocardiogram.
      Figure thumbnail gr1
      Figure 1Proportion of patients with acute myocardial infarction with out-of hospital cardiac arrest from the Black, Asian, or minority ethnicity (BAME) group.

      Processes of care

      The BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001), receive coronary angiography (BAME group, 88%; White group, 79.6%; P < 0.001), and receive PCI (BAME group, 45%; White group, 39.5%; P < 0.001). Administration of dual antiplatelet therapy (BAME group, 75.6%; White group, 77.6%; P = 0.12) and most of the other evidence-based medications, such as beta blockers (BAME group, 70.2%; White group 70.1%; P = 0.93) and fondaparinux (BAME group, 11.9%; White group, 14.1%; P = 0.054) in the BAME group was relatively similar that in the White group, as illustrated by Table 2. However, angiotensin-converting enzyme inhibitors (BAME group, 59.9%; White group, 54.7%; P = 0.002) were more commonly administered in the BAME group, whereas statins (BAME group, 55%; White group, 58.2%; P = 0.034) were more commonly administered in the White group. After adjusting for baseline risk-factor differences, those in the BAME group were more likely to receive coronary angiography than those in the White group (OR 1.5, 95% CI 1.2-1.88) (Supplemental Table S2).
      Table 2Processes of care and unadjusted clinical outcomes of patients with acute myocardial infarction with out-of-hospital cardiac arrest
      LevelWhiteBAMEP
      n13,1021185
      Seen by cardiologist11,950 (92.5)1123 (95.9)< 0.001
      LMWH5379 (50.0)430 (43.9)< 0.001
      Unfractionated heparin4497 (42.1)378 (38.7)0.044
      Fondaparinux1507 (14.1)115 (11.9)0.054
      Aspirin11,674 (93.4)1075 (94.8)0.069
      GP IIIa/IIb inhibitors1716 (15.7)161 (16.3)0.64
      P2Y12 inhibitors10,064 (81.8)881 (80.3)0.21
      DAPT9700 (77.6)857 (75.6)0.12
      Furosemide3066 (28.8)272 (28.4)0.78
      Oral beta-blockers7471 (70.1)682 (70.2)0.93
      Discharged on beta-blockers7201 (56.8)629 (53.9)0.053
      ACEI5915 (54.7)584 (59.9)0.002
      Statins7371 (58.2)643 (55.0)0.034
      Coronary angiography10,031 (79.6)1013 (88.2)< 0.001
      PCI3707 (39.5)412 (45.4)< 0.001
      CABG368 (3.9)34 (3.7)0.80
      In-hospital death3491 (26.6)370 (31.2)< 0.001
      Re-infarction286 (2.3)40 (3.6)0.008
      Bleeding397 (3.1)33 (2.8)0.63
      Values are n (%), unless otherwise indicated.
      ACEI, angiotensin-conversting enzyme inhibitor; BAME, Black, Asian, or minority ethnicity; CABG, coronary artery bypass graft; DAPT, dual antiplatelet therapy; GP, glycoprotein; LMWH, low-molecular-weight heparin; LV, left ventricle; MI, myocardial infarction; NSTEMI, non-STEMI; PCI, percutaneous coronary intervention; STEMI, ST elevation myocardial infarction.

      Clinical outcomes

      The BAME group had a higher crude in-hospital mortality (BAME group, 31.2%; White group, 26.6%; P < 0.001) and re-infarction (BAME group, 3.6%; White group, 2.3%; P = 0.008) rates than the White group. The bleeding rate was not significantly different between the 2 groups (BAME group, 2.8%; White group, 3.1%; P = 0.63). The crude in-hospital mortality rate in the White group has not changed over the past decade; in contrast, in-hospital mortality in BAME patients doubled, from around 16% in 2010 to around 30% in 2017 (Fig. 2).
      Figure thumbnail gr2
      Figure 2Crude in-hospital mortality rate of patients with acute myocardial infarction with out-of hospital cardiac arrest from the Black, Asian, or minority ethnicity (BAME) group.
      After adjusting for the comorbidities and in-hospital management, the BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) rates than the White group, as shown in Table 3.
      Table 3Adjusted clinical outcomes of patients with acute myocardial infarction with out-of-hospital cardiac arrest, and ethnicity odds ratio (OR)
      OutcomeBAME

      OR (95% CI)
      In-hospital death1.26 (1.04–1.52)
      Re-infarction1.52 (1.06–2.18)
      Bleeding0.88 (0.61–1.29)
      Reference is White patients.
      BAME, Black, Asian, or minority ethnicity; CI, confidence interval.

      Sensitivity analysis

      We did a sensitivity analysis to compare the clinical characteristics, management strategies, and clinical outcomes among the Black population, the Asian population, and other non-White ethnic minorities (Other), using the White group as a reference. Clinical characteristics for each ethnic group are presented in Supplemental Table S3; pharmacotherapy, management strategies, and crude in-hospital clinical outcomes are presented in Supplemental Table S4. After adjustment, the Black population rates of in-hospital death (OR 0.88, 95% CI 0.52-1.5) and receipt of coronary angiography (OR 1.5, 95% CI 0.84-2.77) were similar to those in the White population. In contrast, the in-hospital death rate was higher in the Asian population (OR 1.4, 95% CI 1.1-1.78). Table 4 shows the clinical outcomes of the individual racial groups that make up the BAME group. Figure 3 shows the independent predictors of in-hospital mortality of white and BAME patients.
      Table 4Sensitivity analysis of clinical outcomes of patients with acute myocardial infarction with out-of-hospital cardiac arrest, and ethnicity odds ratio (OR)
      OutcomeBlackAsianOther ethnicities
      In-hospital death0.88 (0.52–1.51)1.4 (1.10–1.78)1.17 (0.85–1.62)
      Re-infarction2.1 (0.89–1.5)1.79 (1.17–2.73)0.8 (0.34–1.8)
      Bleeding0.7 (0.21–2.2)1.05 (0.67–1.66)0.67 (0.32–1.37)
      Receipt of coronary angiography1.53 (0.84–2.77)1.38 (1.05–1.82)1.81 (1.18–2.78)
      Reference is White patients. Values are OR (95% confidence interval).
      Figure thumbnail gr3
      Figure 3Independent predictors of in-hospital mortality of White and Black, Asian, or minority ethnicity (BAME) patients. CABG, coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disorder; DAPT, dual antiplatelet therapy; DM, diabetes mellitus; FH, family history; LV, left ventricular; LMWH, low-molecular-weight heparin; MI, myocardial infarction; NSTEMI; non-ST segment elevation myocardial infarction; PCI, percutaneous coronary intervention; PMH, past medical history; PVD, peripheral vascular disease.

      Discussion

      In this national cohort of AMI patients presenting with OHCA, the BAME patients were younger, had a relatively higher-risk comorbidity profile, and were sicker at the time of presentation, with a greater frequency of STEMI, cardiogenic shock, and severe left ventricular impairment, compared with the White population. BAME patients also had a relatively higher frequency of cardiovascular comorbidities such as diabetes, hypertension, and history of previous PCI. Administration of evidence-based medications and processes of care in BAME patients was often better, with BAME patients more likely to be seen by a cardiologist and to receive coronary angiography than the White population. Despite this, the in-hospital mortality rate of BAME patients was significantly higher than that of their White counterparts, with the worst outcomes seen in the Asian population.
      Notably, BAME patients often had better administration of evidence-based medications and process of care, compared with the White population. The BAME population was much younger than the White population, sicker at the time of presentation, and had a higher prevalence of cardiovascular risk factors. These differences might have encouraged physicians to adopt a more invasive approach for management of the BAME patients. Furthermore, BAME patients were more likely to present with STEMI, which may also contribute to higher rates of coronary angiography use in this patient population. The MINAP registry does not capture data relating to optimization to target, which is an important component of quality of care, and so cannot inform as to whether there are significant differences in this factor in the patient groups studied.
      Previous studies on the link between ethnicity and in-hospital management of OHCA revealed that ethnic minorities had a lower rate of inpatient cardiac procedures compared to Whites. For instance, a registry study from the Los Angeles County Emergency Medical Services system in 2019 revealed that minority groups, particularly the Black and Asian populations, had a lower frequency of in-hospital interventions, such as coronary angiography and PCI.
      • Bosson N.
      • Fang A.
      • Kaji A.H.
      • et al.
      Racial and ethnic differences in outcomes after out-of-hospital cardiac arrest: Hispanics and Blacks may fare worse than non-Hispanic Whites.
      Groeneveld et al. examined the rates of cardiac procedure utilization and long-term survival after cardiac arrest. Their study showed that the Black population was less likely to undergo potentially life-saving procedures.
      • Groeneveld P.W.
      • Heidenreich P.A.
      • Garber A.M.
      Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest.
      In the current analysis of a national cohort of patients with AMI with OHCA from England and Wales, we report that BAME patients had better access to some aspects of inpatient management, such as receiving cardiologist input and use of coronary angiography and PCI. These findings suggest that, in contrast to findings in studies performed in the US, there are no significant racial disparities in the in-hospital management of AMI patients presenting with OHCA, and that the differences in the in-hospital processes of care might not contribute to the lower survival rate reported in BAME patients in the United Kingdom.
      The low survival rates in BAME patients reported in the earlier studies from the US were attributed to different factors related to the community response, such as delayed identification of OHCA, longer response time, lack of awareness about OHCA management, and socioeconomic factors along with other social determinants of health.
      • Becker L.B.
      • Han B.H.
      • Meyer P.M.
      • et al.
      Racial differences in the incidence of cardiac arrest and subsequent survival.
      • McNally B.
      • Robb R.
      • Mehta M.
      • et al.
      Out-of-hospital cardiac arrest surveillance— Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010.
      • Merchant R.M.
      • Yang L.
      • Becker L.B.
      • et al.
      Incidence of treated cardiac arrest in hospitalized patients in the United States.
      To the best of our knowledge, this is the first national study from Europe to address the racial disparities in management and outcomes of AMI complicated by OHCA. Our study shows that the crude mortality rate in the BAME population doubled over the study period, in contrast to that in the White population, for whom the in-hospital mortality rate remained relatively stable. Despite being younger and having similar in-hospital care, compared with the White population, BAME patients had higher odds of in-hospital death.
      Survival following OHCA depends to a great extent on a “chain of survival” that begins with early recognition of OHCA and activation of the emergency response system, cardiopulmonary resuscitation (CPR), defibrillation, advanced life support, and integrated care after OHCA.
      • Kronick S.L.
      • Kurz M.C.
      • Lin S.
      • et al.
      Part 4: systems of care and continuous quality improvement: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
      The efficiency of this chain of survival is linked to socioeconomic status and neighbourhood characteristics.
      • Sasson C.
      • Magid D.J.
      • Chan P.
      • et al.
      Association of neighborhood characteristics with bystander-initiated CPR.
      ,
      • Agerström J.
      • Carlsson M.
      • Bremer A.
      • et al.
      Discriminatory cardiac arrest care? Patients with low socioeconomic status receive delayed cardiopulmonary resuscitation and are less likely to survive an in-hospital cardiac arrest.
      For example, Sasson et al. analyzed a large cohort from the Cardiac Arrest Registry to Enhance Survival (CARES) registry in the US and found that patients who had an OHCA in low-income Black neighbourhoods were less likely to receive bystander-initiated CPR than those in high-income White neighbourhoods.
      • Sasson C.
      • Magid D.J.
      • Chan P.
      • et al.
      Association of neighborhood characteristics with bystander-initiated CPR.
      A recent study revealed that patients with low socioeconomic status also receive delayed CPR.
      • Agerström J.
      • Carlsson M.
      • Bremer A.
      • et al.
      Discriminatory cardiac arrest care? Patients with low socioeconomic status receive delayed cardiopulmonary resuscitation and are less likely to survive an in-hospital cardiac arrest.
      Socioeconomic status and level of education were also linked to CPR training disparities, with the White population being trained in CPR more frequently than BAME minorities.
      • Owen D.D.
      • McGovern S.K.
      • Murray A.
      • et al.
      Association of race and socioeconomic status with automatic external defibrillator training prevalence in the United States.
      ,
      • Blewer A.L.
      • Ibrahim S.A.
      • Leary M.
      • et al.
      Cardiopulmonary resuscitation training disparities in the United States.
      As BAME patients tend to have lower socioeconomic status and live in lower-income neighbourhoods, compared with the White population, in the United Kingdom,
      • Kontopantelis E.
      • Mamas M.A.
      • Deanfield J.
      • Asaria M.
      • Doran T.
      Excess mortality in England and Wales during the first wave of the COVID-19 pandemic.
      they have a higher risk of delayed OHCA identification, a less-efficient chain of survival, and subsequently worse clinical outcomes. Moreover, neighbourhoods with a higher incidence of OHCA and low incidence of bystander CPR had a greater proportion of their populations from ethnic minority groups and people not born in the United Kingdom.
      • Brown T.P.
      • Booth S.
      • Hawkes C.A.
      • et al.
      Characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates in England.
      The outcomes of the BAME group can be improved by providing training on CPR and defibrillators to the BAME community members, ensuring adequate availability of defibrillators in the neighbourhoods, and engaging the community centres and leaders in improving community awareness about the importance of the prehospital management of OHCA.
      Our subgroup analysis showed that the Black population had similar survival and revascularization rates, compared with the White population, but the Asian population had a higher risk of in-hospital death and higher rates of coronary angiography and revascularization than the White population. In contrast to our results, the Shah et al. study on the outcomes of OHCA in the South Asian population revealed that the quality of care and admission to survival rates were comparable to those in the White population.
      • Shah A.S.
      • Bhopal R.
      • Gadd S.
      • Donohoe R.
      Out-of-hospital cardiac arrest in South Asian and White populations in London: database evaluation of characteristics and outcome.
      The reasons behind the lower survival rates we reported for the Asian group cannot be fully explained by this study, especially with the small number of Black and Asian patients in the MINAP registry. Nonetheless, clinicians and policymakers may be interested in studying prehospital factors that may contribute to this lower rate, as a step toward reducing mortality in this group.

      Strengths and limitations

      One of the main strengths of this study is that we are able to study whether there are racial disparities in the management and outcomes for patients with AMI presenting with OHCA, from a national registry in which the data were collected prospectively over a long period of time. This study also has limitations that should be considered when interpreting the results. First, as the MINAP registry is an in-hospital AMI registry, it captures only patients with OHCA that complicates AMI, and patients who survived to hospital admission. It provides no insight into outcomes of other types of OHCA, for which there may also be racial disparities. Second, the MINAP database lacks information regarding long-term mortality and other outcomes, and does not capture the appropriateness of treatment decisions related to coronary angiography and inpatient management, nor adherence to and optimal titration of evidence-based medications. There are no data related to intensive-care management such as post-resuscitation cooling and ventilation. Finally, the MINAP registry does not provide any insight into the time to return of spontaneous circulation for those who experience OHCA in the community, or the management and quality of care prior to hospital admission. The MINAP registry does not capture whether differences in the processes of care between the 2 study groups is attributable to a higher prevalence of contraindications to coronary angiography in the White group. Although the MINAP registry provides insight about the neurologic deficit that occurs immediately after OHCA, it does not include information about long-term survival free from neurologic deficit.

      Conclusions

      BAME patients are increasingly presenting with AMI complicated by OHCA and have significantly higher in-hospital mortality compared to the White population, despite consistent inpatient management. The differences in the community response and neighbourhood characteristics that interfere with the chain of survival in BAME patients should be studied and addressed in order to close the gap in the in-hospital survival between the BAME and White populations.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      The authors have no conflicts of interest to disclose.

      Supplementary Material

      References

        • Forslund A.-S.
        • Söderberg S.
        • Jansson J.-H.
        • Lundblad D.
        Trends in incidence and outcome of out-of-hospital cardiac arrest among people with validated myocardial infarction.
        Eur J Prev Cardiol. 2013; 20: 260-267
        • Nichol G.
        • Thomas E.
        • Callaway C.W.
        • et al.
        Regional variation in out-of-hospital cardiac arrest incidence and outcome.
        JAMA. 2008; 300: 1423-1431
        • Atwood C.
        • Eisenberg M.S.
        • Herlitz J.
        • Rea T.D.
        Incidence of EMS-treated out-of-hospital cardiac arrest in Europe.
        Resuscitation. 2005; 67: 75-80
        • Sasson C.
        • Magid D.J.
        • Chan P.
        • et al.
        Association of neighborhood characteristics with bystander-initiated CPR.
        N Engl J Med. 2012; 367: 1607-1615
        • Agerström J.
        • Carlsson M.
        • Bremer A.
        • et al.
        Discriminatory cardiac arrest care? Patients with low socioeconomic status receive delayed cardiopulmonary resuscitation and are less likely to survive an in-hospital cardiac arrest.
        Eur Heart J. 2021; 42: 861-869
        • Shah K.S.V.
        • Shah A.S.V.
        • Bhopal R.
        Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse.
        Eur J Prev Cardiol. 2014; 21: 619-638
        • Chen J.
        • Rathore S.S.
        • Radford M.J.
        • Wang Y.
        • Krumholz H.M.
        Racial differences in the use of cardiac catheterization after acute myocardial infarction.
        N Engl J Med. 2001; 344: 1443-1449
        • Sayegh A.J.
        • Swor R.
        • Chu K.H.
        • et al.
        Does race or socioeconomic status predict adverse outcome after out of hospital cardiac arrest: a multi-center study.
        Resuscitation. 1999; 40: 141-146
        • Galea S.
        • Blaney S.
        • Nandi A.
        • et al.
        Explaining racial disparities in incidence of and survival from out-of-hospital cardiac arrest.
        Am J Epidemiol. 2007; 166: 534-543
        • Cowie M.R.
        • Fahrenbruch C.E.
        • Cobb L.A.
        • Hallstrom A.P.
        Out-of-hospital cardiac arrest: racial differences in outcome in Seattle.
        Am J Public Health. 1993; 83: 955-959
        • Kerr D.J.
        • Scott M.
        British lessons on health care reform.
        N Engl J Med. 2009; 361: e21
      1. Moledina SM, Shoaib A, Weston C, et al. Ethnic disparities in care and outcomes of non-ST-segment elevation myocardial infarction: a nationwide cohort study. Eur Heart J Qual Care Clin Outcomes April 21, 2021 [online ahead of print]; https://doi.org/10.1093/ehjqcco/qcab030.

        • Birkhead J.S.
        • Weston C.F.M.
        • Chen R.
        Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP).
        Heart. 2009; 95: 1593-1599
        • Rashid M.
        • Curzen N.
        • Kinnaird T.
        • et al.
        Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: nationwide analysis from MINAP.
        Int J Cardiol. 2020; 301: 7-13
        • Rashid M.
        • Kontopantelis E.
        • Kinnaird T.
        • et al.
        Association between hospital cardiac catheter laboratory status, use of an invasive strategy, and outcomes after NSTEMI.
        Can J Cardiol. 2020; 36: 868-877
        • Herrett E.
        • Smeeth L.
        • Walker L.
        • Weston C.
        • MINAP Academic Group
        The Myocardial Ischaemia National Audit Project (MINAP).
        Heart. 2010; 96: 1264-1267
        • Wu J.
        • Mamas M.
        • Rashid M.
        • et al.
        Patient response, treatments, and mortality for acute myocardial infarction during the COVID-19 pandemic.
        Eur Heart J Qual Care Clin Outcomes. 2021; 7: 238-246
        • Alpert J.S.
        • Thygesen K.
        • Antman E.
        • Bassand J.P.
        Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.
        J Am Coll Cardiol. 2000; 36: 959-969
        • National Archives
        National Health Service Act 2006.
        (Available at:)
        • Bosson N.
        • Fang A.
        • Kaji A.H.
        • et al.
        Racial and ethnic differences in outcomes after out-of-hospital cardiac arrest: Hispanics and Blacks may fare worse than non-Hispanic Whites.
        Resuscitation. 2019; 137: 29-34
        • Groeneveld P.W.
        • Heidenreich P.A.
        • Garber A.M.
        Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest.
        Circulation. 2003; 108: 286-291
        • Becker L.B.
        • Han B.H.
        • Meyer P.M.
        • et al.
        Racial differences in the incidence of cardiac arrest and subsequent survival.
        N Engl J Med. 1993; 329: 600-606
        • McNally B.
        • Robb R.
        • Mehta M.
        • et al.
        Out-of-hospital cardiac arrest surveillance— Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010.
        MMWR Surveill Summ. 2011; 60: 1-19
        • Merchant R.M.
        • Yang L.
        • Becker L.B.
        • et al.
        Incidence of treated cardiac arrest in hospitalized patients in the United States.
        Crit Care Med. 2011; 39: 2401-2406
        • Kronick S.L.
        • Kurz M.C.
        • Lin S.
        • et al.
        Part 4: systems of care and continuous quality improvement: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S397-S413
        • Owen D.D.
        • McGovern S.K.
        • Murray A.
        • et al.
        Association of race and socioeconomic status with automatic external defibrillator training prevalence in the United States.
        Resuscitation. 2018; 127: 100-104
        • Blewer A.L.
        • Ibrahim S.A.
        • Leary M.
        • et al.
        Cardiopulmonary resuscitation training disparities in the United States.
        J Am Heart Assoc. 2017; 6e006124
        • Kontopantelis E.
        • Mamas M.A.
        • Deanfield J.
        • Asaria M.
        • Doran T.
        Excess mortality in England and Wales during the first wave of the COVID-19 pandemic.
        J Epidemiol Community Health. 2021; 75: 213-223
        • Brown T.P.
        • Booth S.
        • Hawkes C.A.
        • et al.
        Characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates in England.
        Eur Heart J Qual Care Clin Outcomes. 2019; 5: 51-62
        • Shah A.S.
        • Bhopal R.
        • Gadd S.
        • Donohoe R.
        Out-of-hospital cardiac arrest in South Asian and White populations in London: database evaluation of characteristics and outcome.
        Heart Br Card Soc. 2010; 96: 27-29