Wide Racial Disparities Found in Heart Device Implantation
DURHAM, N.C. -- African-Americans are significantly less
likely than white Americans to receive expensive high-tech
implantable defibrillators into the chest to keep their hearts
beating regularly, according to a new analysis by cardiologists
at Duke University Medical Center.
While the exact reasons for this marked disparity are
unclear, the researchers believe that the major barrier facing
African-Americans is a lack of access to the latest in
appropriate care. Less important factors are patient
preferences against invasive procedures and physician bias,
At issue are implantable cardioverter-defibrillators (ICD),
devices the size of a deck of cards that are surgically
implanted under the skin of the chest, with wires attached to
the heart. Whenever the ICD senses that the heart is either
beating too fast or too slow, it delivers an appropriate
electric impulse to bring the heart back into proper rhythm.
ICDs have been proven effective in reducing sudden cardiac
death in patients who have already suffered heart attacks.
"As the technology for cardiac devices improves, it is
imperative that all patients have equal access to these
innovative and life-saving therapies," said DCRI cardiology
fellow Kevin Thomas, M.D., who reported the results of his
analysis Nov. 15, 2005, at the annual scientific sessions of
the American Heart Association in Dallas. "These findings are
in line with other studies that have found racial disparities
when it comes to other procedures for cardiovascular disease,
including coronary artery bypass surgery and angioplasty."
Recent trials have demonstrated the ability of ICDs to
prevent sudden cardiac deaths in patients who have already
suffered from a heart attack. The ICDs also help those whose
hearts have significantly impaired pumping ability, a situation
that often leads to heart failure. Compared to other racial
groups, African-Americans with heart failure suffer the highest
rates of sudden cardiac death..
To determine whether there were any racial disparities in
ICD implantation, Thomas consulted the National Registry to
Advance Heart Health (ADVANCENT), which collects detailed
clinical data on these heart failure patients receiving care at
more than 100 centers in the U.S. He identified 6,453 patients
who met sudden cardiac death primary prevention criteria for
Of those 6,453 patients, 477 were African-American and 5,976
were white. About 37 percent of African-Americans received an
ICD, compared to 46 percent for whites.
"In our analysis, even after adjusting for the differences
between African-Americans and whites in clinical
characteristics and socioeconomic factors, white patients still
had a significantly higher likelihood of receiving an ICD,"
Thomas believes that a lack of access to the health care
system is the main reason why African-Americans do not receive
the latest cardiac technologies at the same rates as whites.
While this lack of access is due to such factors as lack of
insurance coverage, transportation and available health care,
there are other access issues at work, he said.
"Many African-Americans live in either urban or rural areas,
where it is difficult to find cardiologists, much less those
with special electrophysiology training," Thomas said. "Also,
we know that many African-Americans with cardiovascular disease
are not being cared for by cardiologists so there may be a lack
of knowledge about ICDs and their possible benefits.
Furthermore, African Americans relative to white Americans are
less likely to be cared for at hospitals that perform at the
highest levels of national quality of care indicators. These
issues must be addressed."
Thomas pointed out that about 90 percent of the patients
included in his study were treated by cardiologists, which
leads him to believe that the rates of ICD implantation are
even lower in the U.S. as a whole.
To a lesser extent, Thomas believes that there may be some
physician bias against African-Americans, whether intentional
or not. Also, Thomas said that in general African-Americans
have an historical mistrust of the medical system, and they may
not be willing to undergo an invasive procedure.
"A big part of that mistrust is communication," Thomas said.
"If the African-American patient doesn't have a complete
understanding of the procedure, or it is not explained well,
they may decline the procedure. If an African-American
physician or a culturally sensitive health care provider
explained the procedure and what it entailed, more
African-American patients might agree."
Thomas found it quite telling that African-Americans and
whites were prescribed evidence-based medicines such as
aspirin, beta-blockers, ACE inhibitors and anti-arrhythmic
drugs at the same rates, but not when it came to the high-tech
expensive ICD therapy.
Equipped with the knowledge of such disparities proven by
this and other studies, Thomas said that future studies need to
address specific strategies for solving the problem. For
example, he suggested that educational videos be produced with
the same information but introduced by people of different
"We need to continue to push education and awareness that
these racial disparities are real, and to get more people
interested in doing something about it," Thomas continued.
The ADVANCENT registry is supported by Guidant Corp., one of
the manufacturers of ICDs. Thomas has no financial interests in
Guidant. His analysis was supported by the Duke Clinical