This study assessed racial differences in the use of medications and invasive procedures for patients with acute myocardial infarction in the Veterans Affairs (VA) health care system and compared the short- and long-term mortality for these patients.

The data included all male patients with a primary diagnosis of acute myocardial infarction discharged from acute care VA facilities in 1994 or 1995. Of the 4,611 patients, 13.1% were black. Black patients were more likely than white patients to seek treatment at the hospital more than 12 hours after the onset of acute myocardial infarction symptoms (34.4% versus 27.7%) and were more likely to have a history of CHF, hypertension, and stroke. However, the two groups had similar levels of diabetes mellitus, peripheral arterial disease, prior PTCA, and blood pressure.

With regard to medications, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival, using either the entire sample or restricting the comparison to those who were ideal candidates (32.4% versus 48.2%). This comparison demonstrated that racial differences existed in the use of this therapy, even among those arriving within the eligible time window or without a classic presentation.

Black and white patients were equally likely to receive beta-blockers at the time of discharge. Among ideal candidates, black patients were marginally more likely than whites to receive angiotensin converting enzyme inhibitors at discharge (55.7% versus 49.6%, p=0.07) and were more likely to receive aspirin (86.8% versus 82%, p<0.05).

With regard to invasive procedures, there were few race differences. There was no racial pattern in refusal of angiogram, rates of angiogram, refusal of PTCA, rates of PTCA, or refusal of bypass surgery. However, blacks were less likely than whites to undergo bypass surgery at the time of index admission and within 90 days after this admission (6.9% versus 12.5%, p<0.001). In the two subgroups of patients with severe disease (severe coronary artery disease and left main or 3-vessel disease), blacks were more likely to refuse bypass surgery and the rate of bypass surgery was lower. There were no significant race patterns in mortality at 30 days, 1 year, or 3 years.

The authors conclude that “the findings that black patients were as likely or more likely than white patients to receive beneficial medications and diagnostic angiography, but less likely to receive thrombolytic therapy or coronary artery bypass graft surgery, might indicate bias on the part of physicians. As a reflection of unconscious or conscious bias, physicians might be less willing to use invasive procedures or “scarce” resources in minority patients, whom they perceive as less compliant with treatment plans or less likely to benefit. Physicians might be also less likely to withhold medication and interventions that do not require intensive use of hospital resources…Problematic physician-patient communication could also be responsible for some of the disparities in use of invasive therapies…”