Abstract 3778: Racial and Ethnic Differences in Cardiac Resynchronization Therapy Outside of Published Guidelines

Abstract

Objective Ethnic and racial disparities in cardiac care may partially result from over-provision of care among white patients. We hypothesized that whites were more likely than blacks and Hispanics to receive cardiac resynchronization therapy with defibrillator (CRT-D) devices outside of ACC/AHA/HRS guidelines. Methods We analyzed 01/2005– 04/2007 data from the ACC-National Cardiovascular Data Registry for implantable cardioverter-defibrillators (ICDs). We identified white, black and Hispanic patients who received CRT-D. We then fit a multivariable hierarchical logistic regression model with full ACC/AHA/HRS guideline concordance (QRS duration >=0.12 ms, LVEF <<26>35%, and class III or IV CHF) as a binary outcome. Independent variables included race/ethnicity, age, gender, cardiomyopathy etiology, duration of CHF, LVEF, blood pressure, QRS duration/morphology, prior coronary revascularization, atrial fibrillation, cerebrovascular disease, hypertension, diabetes, renal failure, and pulmonary disease. Results Of 108,341 registry patients, 39,088 CRT-D recipients were selected, including 33,310 (85%) non-Hispanic whites, 3,963 (10%) non-Hispanic blacks, and 1,815 (5%) Hispanics. Among all CRT-D recipients, univariate analyses indicated 9,430 (24%) patients lacked 1 CRT-D criterion, 1,840 (5%) patients lacked 2 criteria, and 217 (1%) patients lacked all 3 criteria. Specifically, 2,271 (6%) had an LVEF >35%, 6,758 (17%) had class I/II CHF, and 4,732 (12%) had a QRS duration <0.12 ms. In multivariate analyses, blacks (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.04 –1.23; p=0.004) and Hispanics (OR 1.10, 95% CI 0.97–1.24; p=0.13) were more likely to meet all 3 CRT-D eligibility criteria than non-Hispanic whites. Conclusions After multivariate adjustment, we observed greater guideline-concordant use of CRT-D among blacks and Hispanics than among non-Hispanic whites. Although it is possible that patients receiving CRT-D outside of published guidelines had other compelling clinical findings unrecorded in the registry, such as echocardiographic evidence of dyssynchrony, our findings suggest that racial and ethnic differences in CRT-D partially may be due to over-provision of this technology among white patients.