Article| Volume 16, ISSUE 2, P44-55, March 2006

Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities

      This paper provides important insights on gender differences across racial and ethnic groups in a Medicare population in terms of the quality of care received for acute myocardial infarction (AMI) and congestive heart failure (CHF) in association with diabetes or hypertension/end-stage renal disease (ESRD). Both race/ethnicity and gender are associated with differences in the diagnostic evaluation and treatment of Medicare recipients with these conditions. In the AMI group, non-Hispanic Black and Hispanic patients of both genders were less likely to receive aspirin or β-blockers than non-Hispanic Whites. These differences persisted for Hispanic women and men even when they presented with ESRD or diabetes. Rates for smoking cessation counseling were among the lowest among non-Hispanic Blacks and Hispanics with AMI–diabetes and non-Hispanic blacks with AMI–hypertension/ESRD. Gender comparisons within racial groups for the AMI and AMI–diabetes groups show that among non-Hispanic Whites, women were less likely to receive aspirin and β-blockers. No gender differences were noted among non-Hispanic Black and Hispanic Medicare recipients. In the CHF group, Hispanics were the racial/ethnic group least likely to have an assessment of left ventricular function (LVF), even if they had diabetes and had lower rates of angiotensin-converting enzyme inhibitor therapy or even if they had combined CHF–hypertension/ESRD. Gender comparisons in both the CHF and CHF–hypertension/ESRD groups show that non-Hispanic White women were less likely to have an LVF assessment than non-Hispanic White men. Among all subjects, having comorbidities with AMI was not associated with higher markers of quality cardiovascular care. Closing the many gaps in cardiovascular care must target the specific needs of women and men across racial and ethnic groups.


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        • Abbott R.D.
        • Donahue R.P.
        • Kannel W.B.
        • Wilson P.W.
        The impact of diabetes on survival following myocardial infarction in men vs women. The Framingham Study.
        JAMA. 1988; 260: 3456-3460
        • ACE Inhibitor Myocardial Infarction Collaborative Group
        Indications for ACE inhibitors in the early treatment of acute myocardial infarction.
        Circulation. 1998; 97: 2202-2212
        • Agency for Healthcare Research and Quality
        National healthcare disparities report. US Department of Health and Human Services, Rockville, MD2003
        • Agency for Healthcare Research and Quality
        National healthcare quality report. US Department of Health and Human Services, Rockville, MD2003
        • Agency for Healthcare Research and Quality
        National healthcare disparities report. US Department of Health and Human Services, Rockville, MD2004
        • Agency for Healthcare Research and Quality
        National healthcare quality report. US Department of Health and Human Services, Rockville, MD2004
        • Agency for Healthcare Research and Quality
        National healthcare disparities report. US Department of Health and Human Services, Rockville, MD2005
        • Agency for Healthcare Research and Quality
        National healthcare quality report. US Department of Health and Human Services, Rockville, MD2005
        • American Heart Association (AHA)
        Heart disease and stroke statistics–2005 update. AHA, Dallas, Texas2005
        • Antiplatelet Trialists’ Collaboration
        Collaborative overview of randomized trials of antiplatelet therapy. I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients.
        British Medical Journal (Clinical Research Edition). 1994; 308: 81-106
        • Bello N.
        • Mosca L.
        Epidemiology of coronary heart disease in women.
        Progress in Cardiovascular Diseases. 2004; 46: 287-295
        • Beta-Blocker Pooling Project (BBPP)
        • The beta-blocker pooling project research group
        Subgroup findings from randomized trials in post infarction patients.
        European Heart Journal. 1988; 9: 8-16
        • Califf R.M.
        • DeLong E.R.
        • Ostbye T.
        • Muhlbaier L.H.
        • Chen A.
        • LaPointe N.A.
        • et al.
        Underuse of aspirin in a referral population with documented coronary artery disease.
        The American Journal of Cardiology. 2002; 89: 653-661
        • Canto J.G.
        • Shlipak M.G.
        • Rogers W.J.
        • Malmgren J.A.
        • Frederick P.D.
        • Lambrew C.T.
        • et al.
        Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.
        JAMA. 2000; 283: 3223-3229
        • Claesson M.
        • Burell G.
        • Birgander L.S.
        • Lindahl B.
        • Asplund K.
        Psychosocial distress and impaired quality of life—Targets neglected in the secondary prevention in women with ischaemic heart disease.
        European Journal of Cardiovascular Prevention and Rehabilitation. 2003; 10: 258-266
        • Colwell J.A.
        • American Diabetes Association
        Aspirin therapy in diabetes.
        Diabetes Care. 2004; 27: S72-S73
        • Cushman W.C.
        • Ford C.E.
        • Cutler J.A.
        • Margolis K.L.
        • Davis B.R.
        • Grimm R.H.
        • et al.
        Success and predictors of blood pressure control in diverse North American settings.
        Journal of Clinical Hypertension. 2002; 4: 393-404
        • Dagenais G.R.
        • Yusuf S.
        • Bourassa M.G.
        • Yi Q.
        • Bosch J.
        • Lonn E.M.
        • et al.
        Effects of ramipril on coronary events in high-risk persons.
        Circulation. 2001; 104: 522-526
        • de Gevigney G.
        • Mosnier S.
        • Ecochard R.
        • Rabilloud M.
        • Cao D.
        • Excoffier S.
        • et al.
        Are women with acute myocardial infarction managed as well as men? Does it have consequences on in-hospital mortality? Analysis of an unselected cohort of 801 women and 1,718 men.
        Acta Cardiologica. 2001; 56: 169-179
        • Fiore M.C.
        • Bailey W.C.
        • Cohen S.J.
        • Dorfman S.F.
        • Goldstein M.G.
        • Gritz E.R.
        Treating tobacco use and dependence. US Department of Health and Human Services, Rockville, MD2000 (Public Health Service)
        • Flather M.D.
        • Yusuf S.
        • Kober L.
        • Pfeffer M.
        • Hall A.
        • Murray G.
        • et al.
        • ACE-inhibitor myocardial infarction collaborative group
        Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction.
        Lancet. 2000; 355: 1575-1581
        • Food and Drug Administration
        FDA approves Bidil heart failure drug for black patients.
        FDA News. 2005 (Available: Accessed July 9, 2005)
        • Gan S.C.
        • Beaver S.K.
        • Houck P.M.
        • MacLehose R.F.
        • Lawson H.W.
        • Chan L.
        Treatment of acute myocardial infarction and 30-day mortality among women and men.
        The New England Journal of Medicine. 2000; 343: 8-15
        • Garg R.
        • Yusuf S.
        • Collaborative group on ACE inhibitor trials
        Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure.
        JAMA. 1995; 273: 1450-1456
        • Grady D.
        • Chaput L.
        • Kristof M.
        Diagnosis and treatment of coronary heart disease in women: Systematic review of evidence on selected topics. Evidence Report/Technology assessment No. 7.
        Prepared by the University of California, San Francisco—Stanford Evidence-based Practice Center under contract # 290-97-0013. Agency for Healthcare Research and Quality, Rockville, MD2003
        • Grundy S.M.
        • Pasternak R.
        • Greenland P.
        • Smith Jr., S.
        • Fuster V.
        Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations.
        Circulation. 1999; 100: 1481-1492
        • Henderson S.O.
        • Magana R.N.
        • Korn C.S.
        • Genna T.
        • Bretsky P.M.
        Delayed presentation for care during acute myocardial infarction in a Hispanic population of Los Angeles county.
        Ethnicity & Disease. 2002; 12: 38-44
        • Horowitz C.R.
        • Rein S.B.
        • Leventhal H.
        A story of maladies, misconceptions and mishaps.
        Social Science & Medicine. 2004; 58: 631-643
        • ICD-9-CM
        International Classification of Diseases. PMIC, Los Angeles2002 (9th Revision; Clinical Modification Hospital Edition)
        • Jonas M.
        • Reicher-Reiss H.
        • Boyko V.
        • Shotan A.
        • Mandelzweig L.
        • Goldbourt U.
        • et al.
        • Bezafibrate Infarction Prevention (BIP) study group
        Usefulness of beta-blocker therapy in patients with non-insulin-dependent diabetes mellitus and coronary artery disease.
        The American Journal of Cardiology. 1996; 77: 1273-1277
        • Kendall M.J.
        • Lynch K.P.
        • Hjalmarson A.
        • Kjekshus J.
        Beta-blockers and sudden cardiac death.
        Annals of Internal Medicine. 1995; 123: 358-367
        • Krein S.L.
        • Vijan S.
        • Pogach L.M.
        • Hogan M.M.
        • Kerr E.A.
        Aspirin use and counseling about aspirin among patients with diabetes.
        Diabetes Care. 2002; 25: 965-970
        • Krumholz H.M.
        • Chen J.
        • Chen Y.T.
        • Wang Y.
        • Radford M.J.
        Predicting one-year mortality among elderly survivors of hospitalization for an acute myocardial infarction.
        Journal of the American College of Cardiology. 2001; 38: 453-459
        • Lonn E.
        • Roccaforte R.
        • Yi Q.
        • Dagenais G.
        • Sleight P.
        • Bosch J.
        • et al.
        Effect of long-term therapy with ramipril in high-risk women.
        Journal of the American College of Cardiology. 2002; 40: 693-702
        • Masoudi F.A.
        • Rathore S.S.
        • Wang Y.
        • Havranek E.P.
        • Curtis J.P.
        • Foody J.M.
        • et al.
        National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction.
        Circulation. 2004; 110: 724-731
        • Mosca L.
        • Appel L.J.
        • Benjamin E.J.
        • Berra K.
        • Chandra-Strobos N.
        • Fabunmi R.P.
        • et al.
        Evidence-based guidelines for cardiovascular disease prevention in women.
        Circulation. 2004; 109: 672-693
        • Mosca L.
        • Ferris A.
        • Fabunmi R.
        • Robertson R.M.
        • American Heart Association
        Tracking women’s awareness of heart disease.
        Circulation. 2004; 109: 573-579
        • Mosca L.
        • Manson J.E.
        • Sutherland S.E.
        • Langer R.D.
        • Manolio T.
        • Barrett-Connor E.
        Cardiovascular disease in women: A statement for healthcare professionals from the American Heart Association. writing group.
        Circulation. 1997; 96: 2468-2482
        • Multicenter Postinfarction Research Group
        Risk stratification and survival after myocardial infarction.
        New England Journal of Medicine. 1983; 309: 331-336
        • Njolstad I.
        • Arnesen E.
        • Lund-Larsen P.G.
        Smoking, serum lipids, blood pressure, and sex differences in myocardial infarction. A 12-year follow-up of the Finnmark Study.
        Circulation. 1996; 93: 450-456
        • O’Connor P.J.
        • Pronk N.P.
        • Tan A.W.
        • Rush W.A.
        • Gray R.J.
        Does professional advice influence aspirin use to prevent heart disease in an HMO population?.
        Effective Clinical Practice. 1998; 1: 26-32
        • Olsson G.
        • Wikstrand J.
        • Warnold I.
        • Manger Cats V.
        • McBoyle D.
        • Herlitz J.
        • et al.
        Metoprolol-induced reduction in postinfarction mortality.
        European Heart Journal. 1992; 13: 28-32
        • Patel A.R.
        • Konstam M.A.
        Recent advances in the treatment of heart failure.
        Circulation. 2002; 66: 117-121
        • Pijna I.L.
        • Buchter C.
        Heart failure in women.
        Cardiology in Review. 2003; 11: 337-344
        • Prichard B.N.C.
        • Cruickshank J.M.
        • Graham B.
        Beta-blockers in the third millenium—When are they really indicated?.
        Journal of Clinical and Basic Cardiology. 2001; 4: 3-9
        • Rea T.D.
        • Heckbert S.R.
        • Kaplan R.C.
        • Smith N.L.
        • Lemaitre R.N.
        • Psaty B.M.
        Smoking status and risk for recurrent coronary events after myocardial infarction.
        Annals of Internal Medicine. 2002; 137: 494-500
        • Roig E.
        • Magrina J.
        • Garcia A.
        • Armengol X.
        • Muxi A.
        • Melis G.
        • et al.
        Prognostic value of exercise radionuclide angiography in low risk acute myocardial infarction survivors.
        European Heart Journal. 1993; 14: 213-218
        • Rolka D.B.
        • Fagot-Campagna A.
        • Narayan K.M.
        Aspirin use among adults with diabetes.
        Diabetes Care. 2001; 24: 197-201
        • Saltzberg S.
        • Stroh J.A.
        • Frishman W.H.
        Isolated systolic hypertension in the elderly.
        The Medical Clinics of North America. 1988; 72: 523-547
        • Schaefer B.M.
        • Caracciolo V.
        • Frishman W.H.
        • Charney P.
        Gender, ethnicity, and genes in cardiovascular disease. Part 2: Implications for pharmacotherapy.
        Heart Disease. 2003; 5: 202-214
        • Shlipak M.G.
        Pharmacotherapy for heart failure in patients with renal insufficiency.
        Annals of Internal Medicine. 2003; 138: 917-924
        • Shorr R.I.
        • Ray W.A.
        • Daugherty J.R.
        • Griffin M.R.
        Antihypertensives and the risk of serious hypoglycemia in older persons using insulin or sulfonylureas.
        JAMA. 1997; 278: 40-43
        • Soumerai S.B.
        • McLaughlin T.J.
        • Spiegelman D.
        • Hertzmark E.
        • Thibault G.
        • Goldman L.
        Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction.
        JAMA. 1997; 277: 115-121
        • Stewart D.E.
        • Abbey S.E.
        • Shnek Z.M.
        • Irvine J.
        • Grace S.L.
        Gender differences in health information needs and decisional preferences in patients recovering from an acute ischemic coronary event.
        Psychosomatic Medicine. 2004; 66: 42-48
        • Suarez L.
        • Barrett-Connort E.
        Interaction between cigarette smoking and diabetes mellitus in the prediction of death attributed to cardiovascular disease.
        American Journal of Epidemiology. 1984; 120: 670-675
        • Tenenbaum A.
        • Fisman E.Z.
        • Schwammenthal E.
        • Adler Y.
        • Benderly M.
        • Motro M.
        • et al.
        Increased prevalence of left ventricular hypertrophy in hypertensive women with type 2 diabetes mellitus.
        Cardiovascular Diabetology. 2003; 2: 14
        • Vaccarino V.
        • Krumholz H.M.
        • Yarzebski J.
        • Gore J.M.
        • Goldberg R.J.
        Sex differences in 2-year mortality after hospital discharge for myocardial infarction.
        Annals of Internal Medicine. 2001; 134: 173-181
        • Whitlock E.P.
        • Williams S.B.
        The primary prevention of heart disease in women through health behavior change promotion in primary care.
        Women’s Health Issues. 2003; 13: 122-141
        • Yudkin J.S.
        Which diabetic patients should be taking aspirin?.
        British Medical Journal. 1995; 311 (Clinical Research Edition): 641-642
        • Yusuf S.
        • Sleight P.
        • Pogue J.
        • Bosch J.
        • Davies R.
        • Dagenais G.
        • The heart outcomes prevention evaluation study investigators
        Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.
        The New England Journal of Medicine. 2000; 342: 145-153


      Rosaly Correa-de-Araujo, MD, MSc, PhD, is a cardiovascular pathologist trained at the National Heart, Lung, and Blood Institute. As the Agency for Healthcare Research and Quality’s Director of Women’s Health and Gender-based Research, Dr. Correa oversees the development of a national research agenda for women in consultation with prominent members of the research community and other government agencies. Her main areas of interest include gender-based research and analysis particularly related to chronic diseases, medication use outcomes and safety, and disparities in health care.


      Beth Stevens, MS, is a Biostatistician with the Colorado Foundation for Medical Care. She serves as the lead statistician for the Centers for Medicare & Medicaid Services—funded National Heart Care Quality Improvement Project.


      Ernest Moy, MD, MPH, is a Senior Service Fellow with the Center for Quality Improvement and Patient Safety in the Agency for Healthcare Research and Quality. Dr. Moy leads the development of the National Healthcare Disparities Report.


      David S. Nilasena MD, MSPH, MS, is a Medical Officer with the Centers for Medicare & Medicaid Services.


      Francis Chesley, MD, is the Director of the Office of Extramural Research, Education, and Priority Populations in the Agency for Healthcare Research and Quality.


      Kelly McDermott, MA, is currently a predoctoral student in health services research at the University of Washington in Seattle.