Predictive risk stratification using HEART (history, electrocardiogram, age, risk factors, and initial troponin) and TIMI (thrombolysis in myocardial infarction) scores in non-high risk chest pain patients: An African American urban community based hospital study.

Validated risk scoring systems in African American (AA) population are under studied. We utilized history, electrocardiogram, age, risk factors, and initial troponin (HEART) and thrombolysis in myocardial infarction (TIMI) scores to predict major adverse cardiovascular events (MACE) in non-high cardiovascular (CV) risk predominantly AA patient population.A retrospective emergency department (ED) charts review of 1266 chest pain patients where HEART and TIMI scores were calculated for each patient. Logistic regression model was computed to predict 6-week and 1-year MACE and 90-day cardiac readmission. Decision curve analysis (DCA) was constructed to differentiate between clinical strategies in non-high CV risk patients.Of the 817 patients included, 500 patients had low HEART score vs. 317 patients who had moderate HEART score. Six hundred sixty-three patients had low TIMI score vs. 154 patients had high TIMI score. The univariate logistic regression model shows odds ratio of predicting 6-week MACE using HEART score was 3.11 (95% confidence interval [CI] 1.43-6.76, P = .004) with increase in risk category from low to moderate vs. 2.07 (95% CI 1.18-3.63, P = .011) using TIMI score with increase in risk category from low to high and c-statistic of 0.86 vs. 0.79, respectively. DCA showed net benefit of using HEART score is equally predictive of 6-week MACE when compared to TIMI.In non-high CV risk AA patients, HEART score is better predictive tool for 6-week MACE when compared to TIMI score. Furthermore, patients presenting to ED with chest pain, the optimal strategy for a 2% to 4% miss rate threshold probability should be to discharge these patients from the ED.

Effect of Race on Outcomes Following Early Coronary Computed Tomographic Angiography or Standard Emergency Department Evaluation for Acute Chest Pain.

Objective: To examine racial differences in outcomes with coronary computed tomographic angiography (CCTA) vs standard emergency department (ED) evaluation for chest pain. Design: Retrospective analysis of the prospective, randomized, multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial. Setting: ED at nine hospitals in the United States. Participants: 940 patients who were Caucasian or African American (AA) presenting to the ED with chest pain. Interventions: CCTA or standard ED evaluation. Main Outcome Measures: Length of stay, hospital admission, direct ED discharge, downstream testing and repeat ED visit or hospitalization for recurrent chest pain at 28 days. Safety end points: missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period. Results: 659 (66%) patients self-identified as Caucasian and 281 (28%) self-identified as AA. AA were younger and more often female compared with Caucasians, had a higher prevalence of hypertension (64% vs 49%, P<.001) and diabetes (23% vs 14%, P<.001) and a lower prevalence of hyperlipidemia (28% vs 51%, P<.001). ACS was more frequent among Caucasians (10% vs 2%, P<.001). Randomization to CCTA resulted in a reduction in median LOS for Caucasians (7.4 vs 24.7 hours, P<.001) and AA (8.9 vs. 26.3, P<.001; P-interaction=.88). Both AA and Caucasian patients experienced greater radiation exposure and more downstream testing with CCTA compared with standard evaluation. Conclusions: Early CCTA reduced median LOS for both AA and Caucasian patients presenting to the ED with chest pain by approximately 17 hours compared with standard evaluation.

Gender, race and the presentation of acute coronary syndrome and serious cardiopulmonary diagnoses in ED patients with chest pain.

OBJECTIVE: To assess the relationship between reported chest pain symptoms and a diagnosis of acute coronary syndrome (ACS) and serious cardiopulmonary diagnoses (SCPD) in black males, white males, black females and white females. METHODS: This was a secondary analysis of a prospective cohort study of 4162 ED patients with chest pain enrolled between 1999 and 2008. We used logistic regression, adjusting for age and cardiovascular comorbidities to test the association between 24 chest pain symptoms and 30-day ACS for the primary outcome and SCPD as the secondary outcome. RESULT: In black males, diaphoresis was associated with ACS (OR 1.47; 95% CI 1.02 to 2.13), while in white males, left arm radiation, pressure/tightness and substernal pain were associated with ACS (OR 1.73, 95% CI 1.16 to 2.59; OR 1.65, 95% CI 1.16 to 2.59; OR 1.51, 95% CI 1.07 to 2.11, respectively). In black females, diaphoresis, palpitations and left arm radiation were associated with ACS (OR 1.66, 95% CI 1.17 to 2.35; 1.66, 95% CI 1.13 to 2.45; 1.44, 95% CI 1.02 to 2.03, respectively) while pleuritic pain, and left anterior chest pain lowered ACS risk (OR 0.69, 95% CI 0.5 to 0.96; 0.54, 95% CI 0.35 to 0.84). No symptoms predicted ACS or SCPD in white females. Fewer but similar symptoms predicted SCPD in white males and black females. No symptoms predicted SCPD in black males. CONCLUSION: Chest pain symptoms are important predictors of ACS and SCPD in certain combinations of race and gender but less so in others. These differences might explain difficulties using symptoms to identify patients at higher or lower risk of ACS and SCPD in practice.

The association between ethnicity and delay in seeking medical care for chest pain: a systematic review.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, and chest pain is one of the most common symptoms of ACSs. A rapid response to chest pain by patients and appropriate management by health professionals are vital to improve survival rates.People from different ethnic groups are likely to have different perceptions of chest pain, its severity and the need for urgent treatment. These differences in perception may contribute to differences in response to chests pain and precipitate unique coping strategies. Delay in seeking medical care for chest pain in the general population has been well documented; however, limited studies have focused on delay times within ethnic groups. There is little research to date as to whether ethnicity is associated with the time taken to seek medical care for chest pain. Consequently, addressing this gap in knowledge will play a crucial role in improving the health outcomes of culturally and linguistically diverse (CALD) patients suffering from chest pain and for developing appropriate clinical practice and public awareness for these populations. OBJECTIVES: The current review aimed to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among CALD populations. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Patients from different ethnic minority groups presenting to emergency departments (EDs) with chest pain. TYPES OF EXPOSURE: The current review will examine studies that evaluate the association between ethnicity and delay in seeking medical care for chest pain among CALD populations. TYPES OF STUDIES: The current review will consider quantitative studies including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. OUTCOMES: The current review will consider studies that measure delay time as the main outcome. The time will be measured as the interval between the time of symptom onset and time to reach an ED. SEARCH STRATEGY: A comprehensive search was undertaken for relevant published and unpublished studies written in English with no date restriction. All searches were conducted in October 2014. We searched the following databases: MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, ProQuest (health databases only), Informit, Sociological Abstracts, Scopus and Web of Science. The search for unpublished studies included a wide range of 'gray literature' sources including national libraries, digital theses repositories and clinical trial registries. We also targeted specific health research, specialist cardiac, migrant health, and emergency medicine organizational websites and/or conferences. We also checked the reference lists of included studies and contacted authors when further details about reported data was required to make a decision about eligibility. METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to being included in the review. Validity was assessed using standardized critical appraisal instruments from the Joanna Briggs Institute. Adjudication was produced by the third reviewer. DATA EXTRACTION: Data were extracted from included articles by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute. DATA SYNTHESIS: The extracted data were synthesized into a narrative summary. Meta-analysis could not be performed due to the heterogeneity of study protocols and methods used to measure outcomes. RESULTS: A total of 10 studies, with a total of 1,511,382 participants, investigating the association between ethnicity and delay met the inclusion criteria. Delay times varied across ethnic groups, including Black, Hispanic, Asian, South Asian, Southeast Asian and Chinese. Seven studies reported delay in hours and ranged from 1.90 to 3.10 h. Delay times were longer among CALD populations than the majority population. The other three studies reported delay time in categories of time (e.g. <1, <4 and <6 h) and found larger proportions of later presentations to the EDs among ethnic groups compared with the majority groups. CONCLUSION: There is evidence of an association between ethnicity and time taken in seeking medical care for chest pain, with patients from some ethnic minorities (e.g. Black, Asian, Hispanic and South Asian) taking longer than those of the majority population. Health promotions and health campaigns focusing on these populations are indicated.

Presenting characteristics and processing times for culturally and linguistically diverse (CALD) patients with chest pain in an emergency department: Time, Ethnicity, and Delay (TED) Study II.

BACKGROUND: To date there has been limited published data presenting the characteristics and timeliness of the management in an Emergency Department (ED) for culturally and linguistically diverse (CALD) patients presenting with chest pain. This study aimed to describe the presenting characteristics and processing times for CALD patients with chest pain compared to the Australian-born population, and current guidelines. METHODS: This study was a cross sectional analysis of a cohort of patients who presented with chest pain to the metropolitan hospital between 1 July 2012 and 30 June 2014. RESULTS: Of the total study population (n=6640), 1241 (18.7%) were CALD and 5399 (81.3%) were Australian-born. CALD patients were significantly older than Australian-born patients (mean age 62 vs 56years, p<0.001). There were no differences in the proportion of patients who had central chest pain (74.9% vs 75.7%, p=0.526); ambulance utilisation (41.7% vs 41.1%, p=0.697); and time to initial treatment in ED (21 vs 22min, p=0.375). However, CALD patients spent a significantly longer total time in ED (5.4 vs 4.3h, p<0.001). There was no difference in guideline concordance between the two groups with low rates of 12.5% vs 13%, p=0.556. Nonetheless, CALD patients were 22% (95% CI, 0.65, 0.95, p=0.015) less likely to receive the guideline management for chest pain. CONCLUSIONS: The initial emergency care was equally provided to all patients in the context of a low rate of concordance with three chest pain related standards from the two guidelines. Nonetheless, CALD patients spent a longer time in ED compared to the Australian-born group.

Ethnicity and pre-hospital care for people with suspected cardiac pain: cross-sectional study.

OBJECTIVES: Few studies have investigated the quality of pre-hospital care by ethnicity. We aimed to investigate ethnic differences in pre-hospital ambulance care of patients with suspected cardiac pain. METHODS: We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected cardiac pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data, clinical measurements, drugs administered and outcomes, such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-White with White patients. RESULTS: There were 7046 patients with suspected cardiac pain, with 4825 who had ethnicity recorded including 4661 (96.6%) White and 164 (3.4%) non-White. After correcting for age, sex, socio-economic status and whether transported to hospital, non-White patients were significantly more likely to have temperature [odds ratio (OR) 2.96, P = 0.007], blood glucose (OR 3.95, P = 0.003), respiratory rate (OR 4.94, P = 0.03) and oxygen saturation (OR 2.43, P = 0.006) recorded. Non-White patients were significantly less likely to be transported to hospital (OR 0.43, P = 0.03). CONCLUSION: There were significant differences in pre-hospital ambulance care for non-White compared with White patients with suspected cardiac pain. These differences could be due to differences in clinical condition or case-mix, language and cultural barriers, limited understanding of appropriate use of health care services, recording bias or true differences in provider management. Further analysis should involve larger and more complete data sets to explore ethnic differences in greater detail.

Computed Tomography-Derived Parameters of Myocardial Morphology and Function in Black and White Patients With Acute Chest Pain.

Blacks have higher mortality and hospitalization rates because of congestive heart failure compared with white counterparts. Differences in cardiac structure and function may contribute to the racial disparity in cardiovascular outcomes. Our aim was to compare computed tomography (CT)-derived cardiac measurements between black patients with acute chest pain and age- and gender-matched white patients. We performed a retrospective analysis under an institutional review board waiver and in Health Insurance Portability and Accountability Act compliance. We investigated patients who underwent cardiac dual-source CT for acute chest pain. Myocardial mass, left ventricular (LV) ejection fraction, LV end-systolic volume, and LV end-diastolic volume were quantified using an automated analysis algorithm. Septal wall thickness and cardiac chamber diameters were manually measured. Measurements were compared by independent t test and linear regression. The study population consisted of 300 patients (150 black-mean age 54 ± 12 years; 46% men; 150 white-mean age 55 ± 11 years; 46% men). Myocardial mass was larger for blacks compared with white (176.1 ± 58.4 vs 155.9 ± 51.7 g, p = 0.002), which remained significant after adjusting for age, gender, body mass index, and hypertension. Septal wall thickness was slightly greater (11.9 ± 2.7 vs 11.2 ± 3.1 mm, p = 0.036). The LV inner diameter was moderately larger in black patients in systole (32.3 ± 9.0 vs 30.1 ± 5.4 ml, p = 0.010) and in diastole (50.1 ± 7.8 vs 48.9 ± 5.2 ml, p = 0.137), as well as LV end-diastolic volume (134.5 ± 42.7 vs 128.2 ± 30.6 ml, p = 0.143). Ejection fraction was nonsignificantly lower in blacks (67.1 ± 13.5% vs 69.0 ± 9.6%, p = 0.169). In conclusion, CT-derived myocardial mass was larger in blacks compared with whites, whereas LV functional parameters were generally not statistically different, suggesting that LV mass might be a possible contributing factor to the higher rate of cardiac events in blacks.

Ethnic differences in clinical outcome of patients presenting to the emergency department with chest pain.

BACKGROUND: Ethnicity, although known to influence cardiovascular outcome in assorted clinical settings, has not been investigated previously as a risk factor in patients presenting to the emergency department with suspected acute myocardial infarction. METHODS: In this multi-ethnic cohort study conducted in Singapore and The Netherlands, 2784 patients presenting to the emergency department with chest pain were enrolled (788 Caucasians, 1281 Chinese, 404 Indians and 311 Malays) and were followed up for 1 year. RESULTS: Although Caucasian patients on average were older and had incurred more cardiovascular adverse events, the Asian ethnic groups carried a greater burden of cardiovascular risk factors. Caucasian and Malay patients were most frequently diagnosed with acute myocardial infarction (Caucasians 11.2%, Chinese and Indians 6.4%, Malays 10.6%, P<0.001), also after correction for baseline differences. Chinese and Indian patients, however, more often had unstable angina. Asian patients had strikingly more extensive coronary artery disease than Caucasian patients (triple-vessel disease: Caucasians 6.5%, Chinese 22.8%, Indians 32.4%, Malays 32.8%, P<0.001) and Chinese patients with myocardial infarction more frequently underwent coronary revascularisation compared with Caucasian patients (Caucasians 41.4%, Chinese 67.5%, Indians 62.5%, Malay 46.7%, P=0.005). Ethnicity was not an independent predictor of major adverse cardiovascular events during 1-year follow-up in all chest pain patients. CONCLUSIONS: The prevalence of myocardial infarction and unstable angina, revascularisation rate and extent of coronary artery disease differ significantly among chest pain patients of different ethnic groups. These findings have important clinical implications and support consideration of ethnicity in risk stratification and determination of the patient management strategy in patients with symptoms suggestive of myocardial infarction.

Connecticut Hospital Readmissions Related to Chest Pain and Heart Failure: Differences by Race, Ethnicity, and Payer.

BACKGROUND: Racial and ethnic disparities in hospital readmissions for several major illnesses and conditions are well-documented. However, due to the data typically used to assess readmission disparities little is known regarding the interplay between race/ethnicity and payer in fostering readmissions. This study used a statewide database of acute-care hospital admissions to examine 30-day readmission rates following hospitalization for chest pain and heart failure byrace/ethnicity and insurance status. METHODS: Connecticut hospital discharge data for patients admitted for Chest Pain-DRG 313 (n = 23,450) and Heart Failure and Shock-DRG 291 and 292 (n = 39,985) from 2008 - 2012 were analyzed using marginal logistic models for clustered data with generalized estimating equations. RESULTS: Results from logistic models indicated that Black patients were significantly more likely to be readmitted within 30 days of discharge following hospitalization for chest pain (OR = 1.19, CI = 1.04, 1.37) than were White patients. Hispanics, but not Blacks, were significantly more likely to be readmitted within 30 days of discharge following hospitalization for heart failure (OR = 1.30, CI = 1.15, 1.47). Rates of 30-day readmission across these conditions were between 50-100% higher among those covered by Medicaid compared to those covered by private payer. Controlling for patient socioeconomic status, patient comorbidities, and payer substantially reduced Black/White differences in the odds of readmission for chest pain but did not reduce Hispanic-White differences for heart failure. CONCLUSIONS: Racial and ethnic disparities were seen in hospital readmission rates for Chest Pain (DRG 313) and Heart Failure and Shock (DRG 291 and 292) when a statewide database that captures all acute care hospital admissions was analyzed. When controlling for patient socioeconomic status, comorbidities, and payer status, the difference in the odds of readmission for chest pain, but not heart failure, was reduced.

Muerte súbita por embolismo pulmonar graso y síndrome torácico agudo en paciente con anemia de células falciformes / Sudden death due to pulmonary fat embolism and acute chest syndrome in patients with sickle cell anemia

El síndrome torácico agudo (STA) es una de las complicaciones más frecuentes de las crisis vasooclusivas en pacientes con anemia de células falciformes; en adultos se manifiesta frecuentemente con dolor torácico y disnea. El embolismo pulmonar graso (EPG) es una de las causas principales de STA. Presentamos un caso donde concurren las 2 entidades, en una mujer de 31 años de edad con antecedentes de anemia de células falciformes de larga evolución y múltiples ingresos hospitalarios, que ingresa por crisis vasooclusiva dolorosa que logra estabilizarse y 4 días después desarrolla un STA, infarto de huesos largos, presentando súbitamente hipotensión con desaturación refractaria a maniobras de reanimación. En la autopsia se demostró la presencia de EPG masivo bilateral (AU)

The acute chest syndrome (ACS), one of the most frequent complications of vaso-occlusive crisis in patients with sickle cell anemia, is often manifested in adults with chest pain and dyspnea. Fatty pulmonary embolism (FPE) is a major cause of ACS. We present a case where the two entities concur in a 31 year old woman with a longstanding history of sickle cell anemia and multiple hospital admissions. She presented with a painful vaso-occlusive crisis which was successfully controlled. However, four days later she developed an ACS, long bone infarction followed by sudden onset of refractory hypotension. The autopsy showed bilateral massive FPE (AU)

Perfil etiológico y estratificación del riesgo en pacientes con dolor torácico agudo / Etiologic profile and risk stratification in patients with acute chest pain

INTRODUCCIÓN: el dolor torácico agudo es la sensación álgida que se manifiesta en el tórax, entre el diafragma y la base del cuello; se destaca el extracardíaco, el cardíaco y los de origen no determinado; puede ser traumático o de otras causas. OBJETIVO: identificar el perfil etiológico y estratificación del riesgo de pacientes con dolor torácico agudo. MÉTODOS: estudio descriptivo longitudinal tipo serie de casos. Se estudió una muestra de 634 pacientes que acudieron a la consulta de cardiología del Hospital Militar Holguín con dolor torácico entre enero y diciembre de 2011. RESULTADOS: el dolor torácico tuvo una incidencia de 60 por cada 100 pacientes. Inicialmente pudieron identificarse el 59 % de los pacientes con dolor torácico coronario, y mediante el seguimiento clínico y estudios complementarios se pudo definir el resto de los casos que ascendió al 66 %. La escala de los factores de riesgo coronario (de 3 a 5 puntos) identificó el 93 %. Se determinó la etiología del dolor en 58 pacientes de los 115 con diagnóstico inicial del dolor de origen indeterminado; en el 13,9 % fue imposible determinarla. En la estratificación del riesgo, los pacientes con riesgo entre intermedio y alto para enfermedad aterosclerótica fueron los que presentaron dolor coronario para un 57,8 % y 27,6 % respectivamente. CONCLUSIÓN: la etiología del dolor en los pacientes con origen no determinado del dolor es coronaria. La incidencia de casos con dolor torácico agudo en el servicio de consulta externa es alta

INTRODUCTION: acute chest pain (ACP) is manifested by peak feeling in the chest, between the diaphragm and the base of the neck. This pain can be extracardiac, heart or undetermined origin; it can be traumatic or by other causes. OBJECTIVE: to identify the etiologic profile and risk stratification of patients with acute chest pain. METHODS: a longitudinal descriptive study was conducted on case. 634 patients were studied. They had chest pain and they attended the cardiology service at Holguin Military Hospital from January to December 2011. RESULTS: chest pain had an incidence of 60 per 100 patients. Initially 59 % were identified in patients with coronary chest pain, and the rest of the cases could be defined by clinical follow-up studies and amounted 66 %. The scale of the coronary risk factors (3 to 5 points) identified 93 %. The etiology of pain was determined in 58 out of 115 patients with an initial diagnosis of undetermined-origin pain; 13.9 % was impossible to determine. In risk stratification, patients with intermediate to high risk for atherosclerotic disease were those with coronary pain which represents 57.8 % and 27.6 % respectively. CONCLUSION: the etiology of pain with undetermined origin is coronary pain. The incidence of patients with acute chest pain in the outpatient service is high..

Comparison of epicardial fat volume by computed tomography in black versus white patients with acute chest pain.

Disparities in the risk of coronary artery disease (CAD) between races may be influenced by differences in the thoracic adipose tissue. We compared computed tomography (CT)-derived volumes of epicardial adipose tissue (EAT), mediastinal adipose tissue (MAT), and pericoronary fat thickness (PFT) and correlations with CAD between black and white patients. This institutional review board-approved Health Insurance Portability and Accountability Act-compliant study included 372 age- and gender-matched black versus white patients (186 black, 54 ± 11 years, 50% men; 186 white, 54 ± 11 years, 50% men) who underwent CT for chest pain evaluation. EAT, MAT, and PFT were measured. The amount of coronary calcium was quantified as calcium score. CAD was defined as ≥50% coronary artery narrowing. EAT and MAT volumes were significantly lower in black than white patients (59 [twenty-fifth to seventy-fifth percentile 39 to 84] vs 97 [67 to 132] cm(3) and 44 [27 to 77] vs 87 [52 to 157] cm(3), for both p <0.001). Mean PFT in black patients was slightly lower than white patients (17.2 ± 3.2 vs 18.1 ± 3.4 mm, p <0.01). The relation between race and extent of adipose tissue remained significant after adjustment for cardiovascular risk factors. Significant correlations were observed between EAT and MAT volumes and calcium score in black and white patients (r = 0.19 to 0.26, p <0.01). For both races, the level of thoracic fat measurements was higher in present versus absent coronary calcification. A greater amount of thoracic fat was found with obstructive CAD only in white patients. In conclusion, CT-derived measurements of thoracic fat differ between symptomatic black and white patients, suggesting a differential relation between thoracic adipose tissue and CAD pathophysiology by race.

Platelet function testing to predict hyporesponsiveness to clopidogrel in patients with chest pain seen in the emergency department.

BACKGROUND: A dual antiplatelet regimen has been shown to reduce the risk of major adverse cardiovascular events after percutaneous coronary intervention. However, there is little information available on inhibition of platelet aggregation in patients with a prior coronary stent presenting with chest pain. This study evaluated the prevalence of hyporesponsiveness to clopidogrel and factors associated with this in patients presenting to our emergency department with chest pain who had previously undergone coronary stent placement and were prescribed dual antiplatelet therapy. METHODS: Responsiveness to clopidogrel was evaluated in a cohort of 533 consecutive stented patients presenting to the emergency department with chest pain. P2Y12 reaction units (PRU) and percent P2Y12 inhibition with clopidogrel were measured in all patients. Of 533 patients, 221 (41.6%) had PRU ≥ 230. A multivariate logistic regression model was used to determine the relationship between hyporesponsiveness to clopidogrel (defined as PRU ≥ 230) and several potential risk factors, ie, gender, age, race, type 1 or type 2 diabetes, hypertension, smoking, chronic renal failure, and obesity. RESULTS: There was a greater risk of hyporesponsiveness in African Americans than in non-African American patients (adjusted odds ratio [OR] = 2.165), in patients with type 2 diabetes than in those without (adjusted OR = 2.109), and in women than in men (adjusted OR = 1.813), as well as a greater risk of hyporesponsiveness with increasing age (adjusted OR = 1.167 per decade). CONCLUSION: There was a high prevalence of hyporesponsiveness to clopidogrel in patients presenting with chest pain and a prior coronary stent. Non-insulin-dependent diabetes mellitus and African American race were the strongest predictors of hyporesponsiveness to clopidogrel, followed by gender and age.

Racial-ethnic biases, time pressure, and medical decisions.

This study examined two types of potential sources of racial-ethnic disparities in medical care: implicit biases and time pressure. Eighty-one family physicians and general internists responded to a case vignette describing a patient with chest pain. Time pressure was manipulated experimentally. Under high time pressure, but not under low time pressure, implicit biases regarding blacks and Hispanics led to a less serious diagnosis. In addition, implicit biases regarding blacks led to a lower likelihood of a referral to specialist when physicians were under high time pressure. The results suggest that when physicians face stress, their implicit biases may shape medical decisions in ways that disadvantage minority patients.

Ethnic variations in chest pain and angina in men and women: Scottish Ethnicity and Health Linkage Study of 4.65 million people.

BACKGROUND: European research on ethnic variations in cardiovascular disease has mostly examined mortality endpoints using country of birth as a proxy for ethnicity. We report on chest pain and angina by ethnic group. DESIGN AND METHODS: Retrospective cohort linking the Census 2001 for Scotland (providing 14 ethnic group categories) and hospital discharge/community and hospital deaths data. Directly age-standardized rates and rate ratios were calculated. Risk ratios were adjusted for age and then highest educational qualification of the individual using Poisson regression. Ratios were multiplied by 100 and 95% confidence intervals (CI) were calculated. The reference was the White Scottish population (100). In the results below, the 95% CI excludes 100. RESULTS: There was raised chest pain mortality/hospital discharge risk in Indian men (rate ratio 141.2), Other South Asian women (rate ratio 140.9), and Pakistanis (rate ratio 216.2 in men, 243.0 in women). Rate ratios were lowest in other White British (rate ratio 76.1 in men, 73.7 in women) and Chinese (rate ratio 67.6 in men, 76.7 in women). Adjustment for age and education attenuated, but did not abolish, differences in other White British (risk ratio from 73.5 to 83.5) and Pakistani (risk ratio from 209.0 to 198.2) male populations and increased them in most others, e.g. other South Asian men (from risk ratio of 128.9 to 140.1). Pakistani populations had the highest risk of angina (rate ratio 189.3 in men, 159.7 in women). Other White British (rate ratio 81.4 for men, 78.0 for women), Other White (rate ratio 89.6 men, 85.2 women), and Chinese (rate ratio 60.5 men, 67.4 women) had the lowest risk. Adjustment for education did not greatly alter these patterns. CONCLUSIONS: There were important ethnic variations. The results call for replication elsewhere in Europe and targeted prevention programmes and vigilant diagnosis and management by clinicians.

Cognitive factors that influence delayed decision to seek treatment among older patients with acute myocardial infarction in Korea.

BACKGROUND: The incidence of acute myocardial infarction (AMI) is rapidly increasing among older adults in Korea. However, the factors associated with a delayed decision to visit a hospital and the reasons for this delay have not been explored adequately among older patients. AIMS: To determine factors predicting a prehospital delay time of > 6 h and to identify the cognitive barriers in the delayed decision of AMI patients aged ≥ 65 years. METHODS: This study adopted a mixed methodological approach using quantitative and qualitative analyses. The sample included 94 male and 71 female patients hospitalized for first-time AMI at a university hospital in Korea. Thematic content analysis was used to identify the themes from the qualitative interview data, and multiple logistic regression analysis was used to predict delayed hospital presentation by > 6 h. RESULTS: The median prehospital delay time was 12 h. Low education level, presence of preinfarction angina pain, and attribution of symptoms to a non-cardiac origin were found to be the predicting factors. From the qualitative data, four meaningful themes including 10 subthemes that influenced the delayed decision were identified. Some culturally peculiar themes were found in this Korean sample. CONCLUSIONS: Educational strategies that focus on these cognitive decision-making barriers should be planned for elderly Korean at high risk for AMI.

Using the Rose Angina Questionnaire cross-culturally: the importance of consulting lay people when translating epidemiological questionnaires.

OBJECTIVES: The Rose Angina Questionnaire (RAQ) is an important measure of coronary heart disease prevalence. It has been shown to perform inconsistently across some ethnic groups in Britain. This study investigates whether the best available versions of the RAQ in Punjabi and Cantonese were linguistically equivalent to the English version. DESIGN: Interviews were carried out with lay people from the Pakistani, Chinese and European-origin communities in Scotland to assess the versions of the RAQ used in the Newcastle Heart Project (the best available versions). For each questionnaire item, participants were asked to elaborate on their understanding of the question and the meaning of keywords or phrases. RESULTS: Problems were discovered with the Punjabi and Cantonese translations of the RAQ. For example, the translation for 'chest' was interpreted by some Pakistani and Chinese women to mean 'breasts'. 'Walking uphill' was translated in Chinese as 'walking the hill', without stipulation of the direction, so that some Cantonese speakers interpreted the question as pertaining to walking downhill. Many Chinese interpreted RAQ items to be referring to breathlessness rather than chest pain due to ambiguous wording. CONCLUSION: Existing versions of the RAQ are unlikely to be yielding data that are cross-culturally valid or comparable. For robust health survey research in languages other than that in which the questionnaire was developed, lay assessment of questionnaires prior to and after translation is a necessity rather than a luxury.

Coronary atherosclerosis in African American and white patients with acute chest pain: characterization with coronary CT angiography.

PURPOSE: To use coronary computed tomographic (CT) angiography to compare the prevalence, extent, and composition of coronary atherosclerotic lesions in African American and white patients with acute chest pain. MATERIALS AND METHODS: The institutional review board waived the requirement for informed consent for this retrospective, HIPAA-compliant matched-cohort study. The authors analyzed the CT angiographic data of 301 patients (150 consecutive African American patients; 151 white control patients; mean age, 55 years ± 11 [standard deviation]; 33% male) with acute chest pain. Each coronary artery segment was evaluated for presence of atherosclerotic plaque, plaque composition (calcified, noncalcified, or mixed), and stenosis. In addition, the noncalcified plaque volume was quantified by using a threshold-based automated algorithm. The presence and extent of atherosclerotic plaque were compared between the groups by using univariate and multivariate regression analyses. RESULTS: While there was no significant difference between the African American and white patients with respect to presence of any plaque (118 [79%] of 150 vs 112 [74%] of 151 patients, respectively; P = .36) or presence of stenosis (26 [17%] vs 37 [24%] patients, respectively; P = .13), the African American patients had a significantly higher prevalence (96 [64%] vs 62 [41%] patients, respectively; P < .001) and volume (median volume, 2.2 vs 1.4 mL, respectively; P < .001) of noncalcified plaque, independent of diabetes and other cardiovascular risk factors (odds ratio, 2.45; 95% confidence interval: 1.52, 4.04). In contrast, the African American patients had a lower prevalence of calcified plaque (39 [26%] vs 68 [45%] white patients, P = .001). CONCLUSION: Study results suggest that atherosclerotic plaque burden and composition, as measured by using coronary CT angiography, differ between African American and white patients, with relatively more noncalcified disease in African Americans and more calcified disease in white individuals. Further research is warranted to determine whether CT plaque characterization can improve cardiac risk prediction in African Americans.