Twenty-five seconds isn’t much time, but that’s how often someone in the U.S. has a coronary event; every minute someone dies from one. Cardiac statistics can be even worse in minority populations. The death rate from heart disease is highest among blacks and ethnic disparities related to myocardial infarction, or MI, exist.
“Minorities tend to present later for both MI and stroke and are being directed less to therapeutic intervention such as thrombolytic therapy,” says Beth Mancini, RN, PhD, associate dean of the school of nursing at the University of Texas at Arlington and chair of the science advisory board for the National Registry of CardioPulmonary Resuscitation.
Studies have shown that black patients are less likely than white patients to receive thrombolytic therapy after acute MI and to receive percutaneous coronary interventions, or PCI. An implantable cardioverter-defibrillator, or ICD, is recommended for patients with heart failure (a common adverse effect of MI) at risk for sudden cardiac arrest. Yet in a study of more than 13,000 patients, reported in the October 3, 2007, issue of JAMA, researchers reported that blacks and women were less likely to receive an ICD on discharge.
Delay and treatment variations can have serious consequences. For example, a study by Quinn and colleagues found that Black patients with acute MI have a higher in-hospital mortality rate than whites.
Waiting Too Long
Hispanics and blacks are less likely to call 911 than whites and to seek immediate care for a possible MI. Researchers are still trying to determine why. Attitudes toward healthcare practitioners may be one factor.
“African Americans lack trust in the healthcare system because of disparity of care,” says Yvonne Singletary, RN, BS, CCRN, RCIS, CVN, senior cardiac cath lab tech/RN at St. Luke’s Episcopal Hospital in Houston.
Another factor may be hospital location. “Academic medical centers are often in urban settings and treat large numbers of uninsured patients. They have state-of-the-art technology, which seems to wipe out disparity,” says Mancini.
Many agree that socioeconomic status plays a role. As Jerry Caldwell, RN, MSN, LP, said, “Having a heart attack isn’t cheap.” Caldwell is the STEMI program coordinator at Scott & White Memorial Hospital, Temple, Texas.
Poorer patients may be under-insured or uninsured. For example, 44% of low-income Hispanics and American Indians/Alaska Natives are uninsured, higher than whites, blacks, and Asians and Pacific Islanders.
Economic status can affect rehospitalization. “Patients are readmitted because they can’t afford to get their meds,” says Marianne Morse, RN, MS, core measure coordinator at Houston Northwest Medical Center.
“Women want to make sure everything is taken care of before they go to the hospital,” says Janie Yanez, RN, BSN, CVN, also a senior cardiac cath lab tech/RN at St. Luke’s Episcopal Hospital. Singletary says her mother was writing checks while in the ICU after an MI. In addition, women tend not to have chest pain but may simply present with jaw pain or shortness of breath.
No matter the source of the discrepancy, Mancini says you can eliminate variations by following guidelines such as those from the American College of Cardiology and the American Heart Association. A strategy for rural hospitals might mean having first responders do a 12-lead ECG in the field, so that patients are taken to a hospital with a cath lab.
Culture and Assessment
Culture plays a role in assessing patients, particularly when it comes to pain, although it’s important not to stereotype. “Black people may tend not to hold back on their pain,” says Singletary, who speculates that one reason may be research showing blacks are under-medicated for pain.
“Hispanics and Latinos “may not want to ‘bother’ you. For men, machismo means they can’t show weakness,” says Yanez. She recommends explaining the importance of reporting pain and suggests using a visual 0-to-10-assessment scale as a tool.
“Being able to read patients requires experience, so younger practitioners are at a disadvantage,” Caldwell adds. “Have a high index of suspicion and use more experienced colleagues as a resource.”
It’s also important to get a complete history of what the person is taking. “They may be taking as many as 15 different medications,” says Singletary. She recommends saying, “Tell me everything that you take.” Be alert for use of herbal or folk medicine and marijuana, which, says Yanez, is not uncommon for Mexicans to use to treat GI and arthritis.
One assessment technique is to look for the leader of the family, who may be able to provide additional information. Singletary says in the black community, that’s usually a woman. For Hispanics/Latinos, the home country may make a difference, says Yanez. “A woman from Venezuela may rely on her husband, but a woman from Mexico may rely on her mother.”
“Respect is a big issue [for Hispanics and Latinos],” she adds. “They tend to respect anyone wearing a lab coat, but also want to be treated respectfully. If they catch any sense that you are exasperated with them, they will shut the door.”
Genetics and Treatment
Overall, once minorities are diagnosed with MI, the needed treatment is the same, a fast trip from the ED to the cardiac cath lab and percutaneous coronary intervention for eligible patients.
Variations in genetics, which includes racial characteristics, is starting to play a role in treatment. Mancini cites the example of morphine: “We now know that some people with a certain genetic make up don’t respond to morphine. We say ‘I’ve given enough to treat six patients,’ but you could give enough to treat 100 patients and it sill wouldn’t work.”
As we learn more about these variations, Mancini says we’ll be able to target “not just groups of people, but even to that specific person.” In the not too distant future, “Algorithms will be much more refined and more patient specific.”
Teach them Well
Caldwell says patient education about lifestyle changes, the need to not delay treatment, and medications, is essential. “Tell them, ‘when you go home, you need to keep taking your medicine even when you feel better,'” he says. “If nurses do patient education after a heart attack well, patients tend not to bounce back [to the hospital].”
“This is the only time you have the patient as a captive audience,” notes Singletary, who finds teaching opportunities even in the cath lab. “They may be there only an hour, but what they hear may stay with them a lifetime.”
Risk factor education is particularly key. Blacks and Hispanics/Latinos have a higher risk of cardiovascular disease than whites and are less aware of their risk factors. In fact, cardiovascular disease is the leading cause of death for blacks age 20 or older, according to the American Heart Association.
“I’ve seen the lack of knowledge about risk factors first hand,” says Singletary, who teaches Search Your Heart, a community-based education program designed by the American Heart Association specifically for blacks and Hispanics. The program is divided into three sections: heart disease and stroke, nutrition, and physician activity. The program is available in Spanish as Conozca Su Corazon. Singletary teaches anywhere she can connect with people, including sororities, community centers, churches, and high schools.
“The only risk factor they usually know about is hypertension,” Singletary says, “They don’t associate diabetes or other conditions with risk for a heart attack.” Even though hypertension is understood to be a risk factor, blacks’ high blood pressure is less well controlled compared to whites. In fact, a recent study estimated that treating blacks’ hypertension on parity with whites could reduce annual death from heat disease by 5,480.
What’s the Evidence?
In some cases, variations between ethnic groups have been reported, but not necessarily confirmed by large clinical trials. Mancini notes the important of evidence-based practice. “Nurses must look for data to see how it applies in their practice,” she says. For example, if a nurse knows that statins may work differently in different ethnic populations, they have a higher level of awareness, while waiting for updated practice guidelines.
Morse adds that it’s important to keep track of how your hospital is meeting national standards. “Core measures are really best practices,” she says. Caldwell also recommends following ACC/AHA guidelines.
As advocates and teachers, nurses are in a prime position to counteract possible effects from disparities. Singletary says, “We have to be excellent extractors of information and excellent teachers.”