The 2021 ACC/AHA/SCAI Coronary Artery Revascularization Guidelines begin with a bold statement.1 In a concerted effort to improve health equity in coronary revascularization practices, the very first Class I recommendations is as follows: “in patients who require coronary revascularization, treatment decisions should be based on clinical indications, regardless of sex or race or ethnicity, and efforts to reduce disparities of care are warranted.” On the surface, this seems to be self-evident. In truth, however, the need to spell out the obvious was necessary. Let’s dissect why.
Disparities and Inequities of Care
Firstly, health disparities exist across the gamut of cardiovascular disease with women and non-White patients disproportionately suffering worse outcomes. The underpinnings for these differences are complex and multifactorial, spanning a variety of socioeconomic factors impacting access to healthcare.
Secondly, inequities in care persist even after patients get into our clinics and hospitals. Unequal outcomes persist even after correcting for comorbidity, health education, presentation, socioeconomic status, regional hospital capability and quality, and insurance and health care access. It turns out that women and non-White patients are offered indicated therapies less often than White male patients. This goes for beyond coronary revascularization. Dr. Zarina Sharalaya (an interventional cardiology fellow at the Cleveland Clinic) and Dr. Quin Capers IV (Associate Dean for Faculty Diversity, Vice Chair for Diversity and Inclusion, and a professor of medicine, Department of Internal Medicine at UT Southwestern) previously reviewed racial disparities for four unequivocally indicated therapies: automatic implantable cardioverter-defibrillator implantations in patients at risk for sudden cardiac death; cardiac resynchronization therapy with defibrillator implantation in patients with severely depressed left ventricular function and refractory heart failure; reperfusion therapy in patients presenting with acute myocardial infarction; and revascularization in patients with critical limb ischemia.2
2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization now published!
Here are my top takeaways!
— Cian McCarthy (@CianPMcCarthy) December 9, 2021
The Need for Guidelines
Lastly, there is no medical or physiological foundation for clinicians to base revascularization decisions on differences in sex, race, or ethnicity. The guideline document offers substantial evidence that women and non-White patients derive as much benefit from coronary revascularizations as White men across a range of clinical presentations spanning cardiogenic shock to stable angina.
The guideline document concludes: “the decision to offer revascularization should be made on the basis of a patient’s clinical characteristics, and preferences and should be the same for all patients, regardless of sex, race, or ethnicity.” Reflecting on these recommendations, Dr. Capers offered the following: “I am so proud of our major cardiology organizations for acknowledging race and sex disparities in coronary revascularization and for stressing that we should be working to eliminate them. To have this included in major inter-societal clinical guidelines is a major step towards health equity. Now we need more pathways and algorithms to follow that will promote health equity.”
Yes – the recommendation seems self-evident. But inequities continue to exist even after patients enter into our care. I am reminded of Dr. Nanette Wenger’s 1993 statement in NEJM: “In women, as in men, chest pain compatible with angina pectoris warrants evaluation for coronary heart disease.”3 This seemingly simple statement was as necessary in 1993 as the new guidelines are today.
♥️the focus on #SDM because that is how the best patient care starts!
— Dr. Martha Gulati “Get Vaccinated Please” (@DrMarthaGulati) December 10, 2021
- Lawton JS, Jacqueline Tamis-Holland CE, Chairz Sripal Bangalore V, et al. CLINICAL PRACTICE GUIDELINE: FULL TEXT 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. J Am Coll Cardiol. Published online 2021. Doi:10.1016/j.jacc.2021.09.006
- Capers Q, Sharalaya Z. Racial Disparities in Cardiovascular Care: A Review of Culprits and Potential Solutions. J Racial Ethn Heal Disparities. 2014;3(1):171-180. Doi:10.1007/S40615-014-0021-7
- Wenger NK, Speroff L, Packard B. Cardiovascular Health and Disease in Women. N Engl J Med. 2010;329(4):247-256. Doi:10.1056/NEJM199307223290406