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Background: Premature mortality under the age of 75 years exacerbates the burden of coronary artery disease (CAD) as the leading cause of death in the nation, with particular concerns being raised about its disproportionate effect on the vulnerable population of the Appalachian region compared to other regions of the United States. It is unknown whether the problem of premature CAD mortality in the Appalachian residents is further aggravated by disparities across various population groups within the Appalachian region itself. We hypothesized that within-region socioeconomic and geographic (rural-urban) disparities, independently of each other, aggravate the premature CAD mortality problem in the Appalachian population. Methods: A population-based study of age-adjusted premature CAD mortality among 25-74 year old residents of the Appalachian region was conducted (n=63,630,221). Counties’ rurality status was defined using the U.S. Department of Agriculture Economic Research Service’s (USDA ERS) Rural-Urban Continuum Codes: of 420 Appalachian counties, 217 were classifies as rural and 203 - as urban. To adjust for multiple covariates, general linear modeling (GLM) analysis was conducted (SAS, ver. 9.4). Results: Age-adjusted premature CAD mortality rates were higher in rural than urban Appalachian counties: 99.0 + 40.2 vs. 78.8 + 26.4 per 100,000 (p+ 7.3% vs. 24.4 + 5.7%, p+ 2.0% vs. 6.7 + 1.2%, p+ 3.5% vs. 16.0 + 3.6%, p+ 3.8% vs. 20.2 + 2.9%, p+ 3.8% vs. 32.0 + 3.5%, p+ 4.5% vs. 29.6 + 4.7%, pbeta 3.322, pbeta 0.947, pbeta -0.532, pbeta 2.761, pbeta 0.652, p Conclusions: Premature CAD mortality in rural Appalachian counties is statistically significantly higher than in urban Appalachian counties. Socioeconomic disparities and modifiable CAD risk factors further aggravate the problem.

Background: Racial disparities in coronary artery disease (CAD) can worsen patient outcomes. While a number of studies have investigated racial disparities in CAD risk factors, the underlying mechanisms of racial disparities in the treatment outcomes in hospitalized CAD patients remain unclear. Hypothesis: We hypothesized that racial disparities in in-hospital CAD mortality are, at least partially, attributed to non-hospital factors that are external to quality of in-hospital care. Methods: We conducted a retrospective cohort study of in-hospital mortality in 9,128,116 hospitalized CAD patients (mean±SD age 72.4±13.0 years; 56.7% males) over a five-year time period. Multivariable logistic regression was used to obtain adjusted odds ratios (aOR) for in-hospital death in relation to patients’ race, adjusting for major clinical and demographic covariates. Results: A total of 349,688 deaths occurred among 9,128,116 hospitalized CAD cases (3.8% mortality). Mortality in patients admitted through the emergency department was higher than in non-emergency admissions (4.3% vs. 2.8%, p Conclusion: Racial disparities in in-hospital mortality for CAD patients do exist. These disparities are attributed to several factors, including the non-hospital factors external to quality of in-hospital care, such as lack of access to a high-quality primary care resulting in emergency admissions with more severe forms of CAD and severe comorbidities.

Background: Besides being a major risk factor for coronary artery disease (CAD), diabetes mellitus (DM) also worsens CAD patients’ prognosis. Percutaneous coronary intervention (PCI) with stenting is an effective treatment procedure for certain categories of CAD patients with DM (CAD-DM). Newer drug-eluting stents (DES) were developed to minimize the occurrence of restenosis known to hinder PCI with older non-drug-eluting stents (non-DES). We hypothesized that disparities in DES utilization and post-procedure mortality would exist in CAD-DM patients. Methods: We conducted a retrospective cohort study of in-hospital mortality in 132,934 CAD-DM patients [mean+SD age: 65.3+11.4 years; 62.7% (83,409 of 132,934) males] after PCI with DES and non-DES in the years 2007,2009. Patient race was classified as white, black, or other Asian, Pacific Islander, Native American). Due to short length of stay, in-hospital death was defined as a binary variable (discharged alive vs. deceased). Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for in-hospital death after DES and non-DES PCI in relation to patients’ race, adjusting for confounders: age, gender, comorbidities, number of stents inserted, number of vessels treated, socio-economic status, emergency department (ED) admission, rural/urban area status. Results: Blacks were less likely to receive newer DES stent than any other racial group: 75.7% blacks, 76.9% whites, 79.0% other (p Conclusions: Racial disparities exist in DES utilization by CAD-DM patients and in post-PCI in-hospital mortality: blacks are least likely to receive DES, but patients of other racial groups are more likely to die after PCI. Further studies investigating the mechanisms responsible for these disparities are warranted.

Background: The two major intervention treatment procedures for coronary artery disease (CAD) are coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with. Besides being a major risk factor for CAD, diabetes mellitus (DM) also impacts unfavorably CAD patients’ prognosis. We hypothesized that racial and socio-economic disparities are associated with post-procedure mortality in CAD patients with DM. Methods: A retrospective cohort study of post-procedure mortality after CABG and PCI in 188,851 CAD patients with DM (mean age 65.5∓11.3 years, 35.3% women) was conducted. In-hospital patient death was a binary outcome of interest. Adjusted odds ratios (OR) were obtained from multivariable logistic regression, adjusted for a number of demographic, socio-economic and clinical confounders, including the severity of comorbid conditions (other than DM) measured by Elixhauser Comorbidity Index, Walraven modification. All results were analyzed with SAS version 9.2. Results: Post-CABG in-hospital mortality was higher than post-PCI (adjusted OR 1.89, 95% CI: 1.72-2.08, p Conclusion: Racial and socio-economic disparities are associated with in-hospital mortality after coronary intervention procedures. Further investigation of mortality disparities in CAD patients with DM is warranted.

BACKGROUND: Racial disparities in treatment procedure mortality contribute to long-term mortality disparities. Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI; coronary angioplasty) are two common revascularization procedures for coronary heart disease (CHD) interventional therapy. In-hospital post-coronary revascularization procedure mortality contributes to long-term, overall CHD mortality. While racial disparities in long-term CHD mortality have been reported, existence of racial disparities in post-procedure mortality remains an open question of important implications. HYPOTHESIS: We hypothesized that racial disparities in post-CABG and post-PCI mortality would exist. METHODS: We conducted a study of in-hospital mortality in 427,864 patients [mean+SD age: 66.1+11.8 years; 68.5% (292,955 of 427,864) males] after CABG and PCI during the years 2007,2009. Patient race was classified as white, black, or other (Asian, Pacific Islander, Native American). Because post-procedure length of stay in the hospital is relatively short (days, not months), post-procedure in-hospital death was defined as a binary variable (discharged alive vs. deceased). Multivariable logistic regression models were used to obtain adjusted odds ratios (OR) for in-hospital death after CABG and PCI in relation to race, adjusting for confounding factors - patient and hospital characteristics (age, gender, socio-economic status, Elixhauser comorbidity measures, emergency department admission, rural/urban area status). RESULTS: Significantly higher percentage of black patients were admitted via emergency department (44.8%) as compared to other (37.8%) and white (36.2%) patients (p CONCLUSIONS: Our findings are indicative of two distinctive patterns of racial disparities in post-coronary revascularization procedure mortality. Blacks have a higher post-CABG mortality and lower post-PCI mortality than whites. Other patients have a higher post-PCI mortality than whites, but similar post-CABG mortality. Further studies of the mechanisms responsible for these racial disparity patterns are needed.