Sex and race disparities in emergency department patients with chest pain and a detectable or mildly elevated troponin.

Abstract

Background: Identifying and eliminating health disparities is a public health priority. The goal of this analysis is to determine whether cardiac testing or outcome disparities exist by race or sex in patients with detectable to mildly elevated serum troponin.

Methods: We conducted a secondary analysis of the CMR-IMPACT trial that randomized patients with symptoms suggestive of acute coronary syndrome and a detectable or mildly elevated troponin measure from 4 US hospitals to an early invasive angiography or cardiac MRI strategy. The primary endpoint was the composite of all-cause mortality, myocardial infarction, cardiac hospital readmission, and repeat cardiac ED. Secondary outcomes were components of the composite and revascularization.

Results: Participants (n = 312, mean age 61 ± 11 years) were 36.2 % non-white and 40.1 % female. The composite outcome occurred in 63.7 % of non-white vs. 49.8 % of white patients (aHR 1.50, 95 % CI 1.08-2.09) and 53.6 % of female vs. 55.6 % of male patients (aHR 0.93, 95 % CI 0.68-1.28). Non-white (aHR 0.57, 95 % CI 0.35-0.92) patients had lower rates of revascularization also less median stenosis (p < 0.001) and stenosis >70 % (p < 0.001) during index cardiac testing. Despite these findings, ACS after discharge was higher among non-white patients (aHR 1.84, 95 % CI 1.11-3.05). Females had lower rates of revascularization (aHR 0.52, 95 % CI 0.33-0.82), but no increase in ACS after discharge (aHR 0.90, 95 % CI 0.55-1.49).

Conclusion: Non-white patients had higher rates of ACS following discharge despite lower rates of obstructive CAD following standardization of index cardiac testing. Future disparity works should explore care following the index encounter.