The Impact of an Acute Myocardial Infarction Guideline and Pathway on Racial Outcomes at a University Hospital

Objective: Historically, African Americans who present with acute myocardial infarction were less likely to survive or be revascularized compared to Whites in the United States. Variation in practice has been implicated as a cause. Some researchers have proposed that the explanation for this variation was that coronary artery disease (CAD) was less severe in African Americans than Whites. A university hospital compared the extent of CAD by race for its acute myocardial infarction (AMI) patients and determined the effect of implementing evidenced-based guidelines on racial differences in cardiovascular outcomes. Methods: From 1991 to 1994, using the National Registry for Myocardial Infarction 1 and the hospital AMI database, 323 of the 521 consecutive patients were catheterized during their initial admission. The extent of CAD was defined as the frequency of CAD stenosis $70% seen in the major coronary arteries and/ or their major branches. Cardiac function was measured by left ventricular ejection fraction (LVEF). Short-term hospitalized outcomes were determined for death, treatment, and coronary revascularization. Results: We assessed 82 (25.4%) African Americans and 241 (74.6%) Whites. No significant difference in the frequency of stenosis $70% or clinical outcomes existed between races. However, African Americans had a lower LVEF of 49.13% compared to 54.98% for Whites (P=.04). African Americans were 2.54 times more likely to have LVEF ,45% (P=0.024). We saw no racial difference in death, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or thrombolytic therapy. Conclusion: In high-risk AMI patients, this study found no difference in the burden of CAD by race. However, for African Americans, left ventricular function was more depressed. The use of an AMI management guideline and pathway-driven protocol resulted in no significant racial difference in cardiac interventions or clinical outcomes. A guideline or protocoldriven approach to the management of AMI may significantly reduce the observed racial variation in quality care