JACC
HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK
QUICK SEARCH:   [advanced]


     

J Am Coll Cardiol, 2000; 36:1870-1876
© 2000 by the American College of Cardiology Foundation
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bridges, C. R.
Right arrow Articles by Coombs, L. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bridges, C. R.
Right arrow Articles by Coombs, L. P.

CLINICAL STUDY: CARDIAC SURGERY

The effect of race on coronary bypass operative mortality

Charles R. Bridges, MD, ScD, FACC*, Fred H. Edwards, MD, FACC{dagger}, Eric D. Peterson, MD, MPH, FACC{ddagger} and Laura P. Coombs, PhD§

* Department of Surgery, the University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
{dagger} Department of Surgery, University of Florida Health Sciences Center, Jacksonville, Florida, USA
{ddagger} Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
§ Duke Clinical Research Institute, Durham, North Carolina, USA

Manuscript received April 6, 2000; revised manuscript received June 9, 2000, accepted July 20, 2000.

Reprint requests and correspondence: Dr. Charles R. Bridges, Department of Surgery, Fourth Floor, Silverstein Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104
cbridges{at}mail.med.upenn.edu


   Abstract
Top
 Abstract
Materials and methods
 Results
 Discussion
 References
 
OBJECTIVES

The study was done to determine whether race is an independent predictor of operative mortality after coronary artery bypass graft (CABG) surgery.

BACKGROUND

Blacks are less frequently referred for cardiac catheterization and CABG than are whites. Few reports have investigated the relative fate of patients who undergo CABG as a function of race.

METHODS

The Society of Thoracic Surgeons National Database was used to retrospectively review 25,850 black and 555,939 white patients who underwent CABG-alone from 1994 through 1997. A multivariate logistic regression model was developed to determine whether race affected risk-adjusted operative mortality.

RESULTS

Operative mortality was 3.83% for blacks versus 3.14% for whites (unadjusted black/white odds ratio [OR] 1.23 [1.15–1.31]). Blacks were younger, more likely female, hypertensive, diabetic and in heart failure. Nonetheless, the influence of these and other preoperative risk factors on procedural mortality was quite similar in black and white patients. After controlling for all risk factors, race remained a significant independent predictor of mortality in the multivariate logistic model (adjusted black/white OR 1.29 [1.21, 1.38]). Proportionately, these differences were greatest among lower-risk patients. The race-by-gender interaction was significant (p < 0.05). The unadjusted mortality for black men, 3.30% and white men, 2.64% differed significantly (p < 0.05), whereas for women there was no difference (black, 4.49%; white 4.41%).

CONCLUSIONS

Black race is an independent predictor of operative mortality after CABG except for very high-risk patients. The difference in mortality is greatest for male patients and, though statistically significant, is small in absolute terms. Therefore, patients should be referred for CABG based on clinical characteristics irrespective of race.

Abbreviations and Acronyms
  BSA = body surface area
  B/W = black/white
  CABG = coronary artery bypass graft
  CAD = coronary artery disease
  CVA = cerebrovascular accident
  CVD = cerebrovascular disease
  COPD = chronic obstructive pulmonary disease
  IABP = intraaortic balloon pump
  LVH = left ventricular hypertrophy
  MI = myocardial infarction
  NYHA = New York Heart Association
  OR = odds ratio
  PVD = peripheral vascular disease

Various studies have shown that black patients are less frequently referred for cardiac catheterization (1–5), percutaneous transluminal coronary angioplasty (PTCA) (1,2,4–13) and coronary artery bypass graft surgery (CABG) (1,2,4–8,10–14) than white patients. In general, these differences cannot be accounted for on the basis of disease severity (3,4,7–9,13,14) or the availability of health insurance or socioeconomic status (2–4,6,8,13). Racial bias on the part of physicians has been implicated as one possible contributing factor (3). It is also worth noting that this racial disparity in the use of revascularization procedures has been associated with lower long-term survival among blacks (7). These observations galvanize the view that efforts need to be made to encourage wider use of revascularization procedures in blacks to address this apparent underutilization. As part of this effort, patients and their physicians should understand the unique risks and benefits of these procedures among black patients. However, to date, there has been relatively limited information on the influence of race on the acute outcomes of bypass surgery.

The Society of Thoracic Surgeons National Cardiac Surgery Database, commonly called the STS Database, provides a unique opportunity to address this important question with statistical rigor and power. This report will analyze the national CABG surgical results taken from patients entered into the STS Database from 1994 through 1997. We sought to answer the following questions: Do blacks have poorer acute outcomes following CABG compared with whites? Are the important preoperative predictors of outcomes similar in black and white patients? Do blacks present later or more emergently for bypass surgery than whites? Is race a significant independent predictor of CABG operative mortality after accounting for other known risk factors?


   Materials and methods
Top
 Abstract
 Materials and methods
Results
 Discussion
 References
 
The population is taken from patients who underwent CABG alone without concomitant procedures, registered in the STS Database from 1994 through 1997. The data represent 47 states (Idaho, Vermont and Maine are not represented), and 5 Canadian provinces (Alberta, Manitoba, Nova Scotia, New Brunswick and Quebec). To be included in the study, patients had to be at least 20 years old and recorded as either black or white on their data collection form. The final analysis included 581,789 patients, of whom 25,850 were black and 555,939 were white.

Patient characteristics were tabulated by race (Table 1), and the differences in proportions for categorical variables were tested using chi-square tests; mean differences for continuous variables were tested using t tests. Overall rates of operative mortality (defined as "mortality occurring at any time in the hospital during the same admission or within 30 days of surgery"), procedural complications and length of stay for blacks and whites were also examined (Table 2). Complications included the following: central neurologic deficit persisting more than 72 h; pulmonary insufficiency requiring ventilatory support; operative re-intervention for bleeding; acute postoperative renal insufficiency; and deep sternal infection involving muscle, bone, and/or mediastinum. Univariate operative mortality rates by risk factor for blacks and whites were also compared (Table 3).


View this table:
[in this window]
[in a new window]
  		Table 1 Patient Characteristics by Race

 

View this table:
[in this window]
[in a new window]
  		Table 2 CABG Mortality, Complications, and Length of Stay by Race

 

View this table:
[in this window]
[in a new window]
  		Table 3 Comparison of Operative Mortality for Specific Subpopulations

 
Next, a logistic regression model of CABG operative mortality was developed using stepwise logistic regression and including all the risk factors as the set of possible predictors. Given the large sample size, independent predictors of mortality were retained in the model if their significance was <0.001. Race was then added to the model to determine whether it had any predictive ability after adjusting for the risk factors already in the model.

Interactions between race and other risk factors were examined in two ways. First, interactions between race and risk factors of interest (e.g., gender, diabetes, hypertension, cerebrovascular [CVA], age, reoperation, shock, obesity) were added to the logistic model to determine their significance. Alternatively, the risk factors from the model developed on all patients were used to model white patients and black patients separately. A comparison of the odds ratio (OR) for the two groups made any differences between blacks and whites more apparent (Table 4).


View this table:
[in this window]
[in a new window]
  		Table 4 Multivariate Logistic Regression Model by Race

 
Finally, the relationship between preoperative risk and race was examined more closely. Specifically, black patients and white patients were classified into decile groupings based on their preoperative risk scores (obtained from the multivariable model with race excluded). Observed mortality rates for blacks and whites in each risk group were then calculated. Graphs of observed mortality by risk decile grouping are presented in Figure 1. Graphs of the black/white ORs using the same decile groupings are presented in Figure 2. To determine whether the difference in mortality rate between blacks and whites was constant across risk score, the race-by-risk interaction was tested for significance using logistic regression.



View larger version (13K):
[in this window]
[in a new window]
  		Figure 1 Race by risk interaction. Observed operative mortality is shown for black and white patients as a function of the preoperative risk group.

 


View larger version (11K):
[in this window]
[in a new window]
  		Figure 2 Comparison of the black:white operative mortality OR for different preoperative risk groups.

 

   Results
Top
 Abstract
 Materials and methods
 Results
Discussion
 References
 
General demographics.   A comparison of clinical preoperative risk factors for blacks and whites (Table 1) shows significant differences between the two groups. Because of the large number of patients in this analysis, nearly all univariate risk factors differ significantly as a function of race (p < 0.01). Several differences are striking, however. In general, black CABG patients were more likely to be female than were white patients (44.4% vs. 27.9%, p < 0.001). Black patients were also younger, having an average age of 61.5 years versus 64.8 years for whites. Black patients were more likely to have hypertension (80.5% vs. 62.4%), diabetes (43.8% vs. 27.8%), morbid obesity (15.4% vs. 11.4%) and renal disease (6.4% vs. 2.3%) than whites. However, we did not find strong evidence that blacks were referred for bypass later or in more emergent states than whites. Specifically, blacks were less likely to have their cases done under urgent, emergent or salvage conditions and had less New York Heart Association (NYHA) class IV symptoms at the time of bypass. Additionally, black patients did not appear to have more severe coronary disease anatomy or markedly worse left ventricular function (Table 1).

Operative outcomes by race.   Table 2 provides the acute outcomes of bypass surgery for black patients and white patients. The operative mortality was 3.83% for blacks and 3.14% for whites, p < 0.001, unadjusted black/white (B/W) OR 1.23 [1.15–1.310]. Similarly, blacks had higher rates of postoperative complications, including stroke (B/W OR 1.36 [1.25, 1.48]), reoperation for bleeding (B/W OR 1.10 [1.02–1.20], prolonged ventilation (B/W OR 1.34 [1.28, 1.40]), renal failure (B/W OR 1.42 [1.34, 1.51]) and deep sternal wound infection (B/W OR 1.22 [1.05, 1.40]). Postoperative length of stays were also slightly longer for black patients (Table 2).

Table 3 shows the operative mortality for blacks and whites among important clinical subsets. The operative mortality was higher for blacks in most risk categories. For one important risk factor, however, blacks had a significantly lower operative mortality. The operative mortality for blacks with renal failure (7.6%) was lower than the operative mortality for whites with renal failure (10.5%), p = 0.0003.

Risk model comparisons.   Using stepwise logistic regression, we identified 27 preoperative characteristics associated with operative mortality. A summary of the results of the logistic regression model appears in Table 4. The risk factors in Table 4 have been arranged according to their contribution to the predictive power of the overall model (as assessed by the value of the Wald chi-square statistic). Thus, age, reoperation, the need for preoperative intraaortic balloon pump (IABP) and ejection fraction emerge as the strong multivariate predictors of operative mortality. The overall ability of this model to discriminate patients who would live from those who would die was excellent (area under the ROC curve or C-statistic = 0.78).

To test whether race was an important independent predictor of operative mortality, we added race to our overall multivariable model. After controlling for the 27 other known risk factors, blacks had 29% higher operative mortality risk compared with whites (adjusted B/W OR 1.29 [1.21, 1.38]). Thus, patient race is an independent risk factor for bypass mortality even after accounting for other differences in patient clinical profiles.

While race is an independent risk factor for procedural outcomes, other known preoperative mortality risk factors among blacks and whites were strikingly similar (Table 4). Specifically, when the multivariable model was applied in black patient and white patient subsets separately, the directionality and magnitude of the ORs for these risk factors were quite similar in blacks and whites (Table 4). We also more formally tested for race by risk factor interactions in the overall patient population. Of the interactions examined, only race by gender was significant (p < 0.05), indicating that the difference in mortality between blacks and whites was more pronounced for men than for women. In fact, there was no significant difference in unadjusted mortality between black and white women (4.49% vs. 4.41%; p = NS).

Finally, the relationship between race and overall mortality risk was examined. Specifically, black patients and white patients were grouped into equal-sized deciles by their calculated operative mortality risk (based on the multivariable model). As demonstrated in Figure 1, blacks had slightly higher observed mortality across all risk deciles. When examined as risk ratios (Fig. 2), however, it becomes clear that B/W mortality differences are greatest among those patients at lowest predicted operative risk. For example, in Decile 1 (lowest-risk patients), the B/W OR for observed mortality was 1.83, whereas among those in Decile 10 (highest risk) this observed B/W mortality risk was only 1.03. In fact, a formal test of race by risk interaction was significant (p < 0.05), indicating that the difference in mortality rates for blacks and whites is not the same across risk groups.


   Discussion
Top
 Abstract
 Materials and methods
 Results
 Discussion
References
 
We used the Society of Thoracic Surgery National Database to study the effect of race on CABG operative mortality for 555,939 white and 25,850 black patients who underwent CABG from 1994 through 1997. Our analysis has indicated that blacks have a higher operative mortality after CABG than white patients with similar risk profiles. This increase in the relative risk of CABG among blacks, however, is modest in absolute terms (3.83% vs. 3.14%) and is concentrated among males and those with low preoperative risk profiles. In fact, black women and white women have equal unadjusted mortality risk, as do patients with high operative risk.

Comparison with previous studies.   Prior to the present study, there have been relatively few published investigations of the effect of race on CABG operative mortality or postoperative long-term survival (15–21). Gray et al. (21) reviewed the records of 3,113 white and 115 black patients who underwent CABG at Cedars-Sinai Medical Center from 1984 through mid-1994. The operative mortality was 5.5% for blacks and 4.6% for whites, p = 0.48. Although there was no significant difference in operative mortality in this study, a multivariate analysis was performed only for long-term survival (21). Higgins et al. (19) analyzed the results of 2,282 white and 494 black patients undergoing CABG from 1990 to 1996 at Henry Ford Hospital in Detroit. The overall operative mortality was 5.5% for black patients and 2.5% for white patients (p < 0.003). However, using multivariate logistic regression, race was not a significant predictor of mortality (19).

Maynard et al. (18) using the Coronary Artery Surgery Study (CASS) database found no statistically significant difference in the five-year survival of patients treated surgically as a function of race. Taylor et al. (20) also using the CASS database, examined the records of 22,714 white and 571 black patients who underwent angiography between 1974 and 1979. Long-term (>10-year follow-up) survival for surgically treated patients was significantly lower for black patients than for white patients, with black race emerging as a significant adverse predictor of long-term survival in a multivariate Cox proportional hazards model.

The search for alternative risk factors.   The reasons for the higher operative mortality observed in black patients in this study are not clear. It is difficult to understand how race per se should have a significant impact on operative mortality once all known risk factors have been considered in a multivariate model. Our results suggest several possible hypotheses. First, we found that the average age of the black CABG patients in our population (61.5 years) is significantly lower than the average age of the white patients (64.8 years; p = 0.0001). Yet if a multivariate analysis is performed excluding race as a variable, the predicted mortality for black patients is 3.12%, whereas the predicted mortality for whites is 3.14%. Despite younger age, black patients have similar predicted mortality independent of race. Thus, black patients were generally younger and slightly sicker for their age than were white patients. Therefore, race in this study may be a marker for patients with more rapid rate of progression of coronary artery disease (CAD), in particular, and vascular disease, in general.

This finding of potentially more aggressive atherosclerosis in black patients is also consistent with the observed higher rates of cerebrovascular disease, hypertension, and renal disease in blacks relative to whites. The factors that correlate with vascular disease progression, such as elevations in C-reactive protein, are likely to be more prevalent in these patients (22). The associated inflammatory milieu is likely to exacerbate end organ function to a greater extent after cardiopulmonary bypass and to increase the risk of cardiac, neurological, pulmonary and renal complications after surgery, as we observed (23) (Table 2). These and other serum factors may also be important in determining CABG operative mortality, considering that the removal of inflammatory mediators using conventional and modified ultrafiltration has recently been shown to improve pulmonary, hemostatic and cardiac function after cardiac surgery in adults (24). Endothelial dysfunction has also been raised (25) as a risk factor for hypertension, and perhaps it could lead to complications in patients after CABG.

Blacks, in the absence of angiographic evidence of CAD, have a significant reduction in endothelium-independent coronary flow reserve compared with whites (25). Additionally, the depressed coronary vascular relaxation in response to both acetylcholine and adenosine in black patients has been associated with the higher prevalence of left ventricular hypertrophy (LVH) seen in blacks (26). For a given degree of hypertension, black patients are more likely to have significant LVH (27). In this analysis, although LVH was not specifically studied, we did, however, note that racial differences in operative mortality appeared to be limited to those patients with hypertension (Table 3). Specifically, although hypertensive blacks had significantly higher operative mortality than whites, race was not a significant predictor of surgical outcome among normotensive patients. The LVH may be more prevalent in the black patients studied with hypertension, perhaps increasing the incidence of postoperative arrhythmias or compromising myocardial protection during cardiopulmonary bypass.

Finally, as previous researchers have indicated, the study of racial differences in care and outcome is complex (28). Dichotomous variables based on skin tone do not capture the ethnic and biological diversity inherent among humans. Additionally, race is often a surrogate marker for underlying socio-economic, educational, behavioral and cultural differences. Unfortunately, these factors were not collected within our study, but the potential influence of these and other nonbiologic factors on both the short- and long-term outcomes of CABG should be the focus of future studies.

Conclusions.   In summary, the finding that race is an independent predictor of operative mortality after CABG should prompt a more careful search for additional risk factors for CABG operative mortality. The unexpected finding of a significant race/gender interaction is important. In the general population, female gender is an independent predictor of operative mortality after CABG (29,30) (Table 4). Thus, further analysis of the differential effects of race and gender on outcome, as functions of gender and race, respectively, is required. Although the operative mortality after CABG is significantly higher for blacks than for whites, the differences are relatively small in absolute terms. Therefore, patients should continue to be referred for CABG based on established clinical criteria, independent of race.


   References
Top
 Abstract
 Materials and methods
 Results
 Discussion
 References
 

  1. Gillum RF, Gillum BS, Francis CK. Coronary revascularization and cardiac catheterization in the United States: trends in racial differences. J Am Coll Cardiol. 1997;29:1557–1562[Abstract]
  2. Mirvis DM, Graney MJ. Impact of race and age on the effects of regionalization of cardiac procedures in the Department of Veterans Affairs Health Care System. Am J Cardiol. 1998;81:982–987[CrossRef][Medline]
  3. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–626[Abstract/Free Full Text]
  4. Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988. Am J Public Health. 1995;85:352–356[Abstract/Free Full Text]
  5. Gillum RF, Mussolino ME, Madans JH. Coronary heart disease incidence and survival in African-American women and men. the NHANES I epidemiologic follow-up study. Ann Intern Med. 1997;127:111–118[Abstract/Free Full Text]
  6. Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM. Racial differences in the use of revascularization procedures after coronary angiography. JAMA. 1993;269:2642–2646[Abstract]
  7. Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB. Racial variation in the use of coronary-revascularization procedures. Are the differences real? Do they matter? N Engl J Med. 1997;336:480–486[Abstract/Free Full Text]
  8. Giles WH, Anda RF, Casper ML, Escobedo LG, Taylor HA. Race and sex differences in rates of invasive cardiac procedures in US hospitals. Data from the National Hospital Discharge Survey. Arch Intern Med. 1995;155:318–324[Abstract]
  9. Ramsey DJ, Goff DC, Wear ML, Labarthe DR, Nichaman MZ. Sex and ethnic differences in use of myocardial revascularization procedures in Mexican Americans and non-Hispanic whites: the Corpus Christi Heart Project. J Clin Epidemiol. 1997;50:603–609[CrossRef][Medline]
  10. McBean AM, Warren JL, Babish JD. Continuing differences in the rates of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery between elderly black and white Medicare beneficiaries. Am Heart J. 1994;127:282–295[CrossRef][Medline]
  11. Blacks in the Coronary Artery Surgery StudyMaynard C, Fisher LD, Passamani ER, Pullum T. : risk factors and coronary artery disease. Circulation. 1986;74:64–71[Abstract/Free Full Text]
  12. Maynard C, Every NR, Martin JS, Weaver WD. Long-term implications of racial differences in the use of revascularization procedures (the Myocardial Infarction Triage and Intervention Registry). Am Heart J. 1997;133:656–662[CrossRef][Medline]
  13. Laouri M, Kravitz RL, French WJ, et al. Underuse of coronary revascularization procedures: application of a clinical method. J Am Coll Cardiol. 1997;29:891–897[Abstract]
  14. Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med. 1993;118:593–601[Abstract/Free Full Text]
  15. Sterling RP, Graeber GM, Albus RA, Burton NA, Lough FC, Fleming AW. Results of myocardial revascularization in black males. Am Heart J. 1984;108:695–699[CrossRef][Medline]
  16. Simmons BE, Castaner A, Campo A, Ferlinz J, Mar M, Cooper R. Coronary artery disease in blacks of lower socioeconomic status: angiographic findings from the Cook County Hospital Heart Disease Registry. Am Heart J. 1988;116:90–97[CrossRef][Medline]
  17. Simmons BE, Castaner A, Mar M, Islam N, Cooper R. Survival determinants in black patients with angiographically defined coronary artery disease. Am Heart J. 1990;119:513–519[CrossRef][Medline]
  18. Maynard C, Fisher LD, Passamani ER. Survival of black persons compared with white persons in the Coronary Artery Surgery Study (CASS). Am J Cardiol. 1987;60:513–518[CrossRef][Medline]
  19. Higgins RS, Paone G, Borzak S, Jacobsen G, Peterson E, Silverman NA. Effect of payer status on outcomes of coronary artery bypass surgery in blacks. Circulation 1998;98:II46–9; Discussion II49–50.
  20. Taylor HA, Mickel MC, Chaitman BR, Sopko G, Cutter GR, Rogers WJ. Long-term survival of African Americans in the Coronary Artery Surgery Study (CASS). J Am Coll Cardiol. 1997;29:358–364[Abstract]
  21. Gray RJ, Nessim S, Khan SS, Denton T, Matloff JM. Adverse 5-year outcome after coronary artery bypass surgery in blacks. Arch Intern Med. 1996;156:769–773[Abstract]
  22. Liao JK. Endothelium and acute coronary syndromes. Clin Chem. 1998;44:1799–1808[Abstract/Free Full Text]
  23. Sablotzki A, Dehne MG, Mann V, et al. Plasma levels of selectins and interleukins in cardiovascular surgery using cardiopulmonary bypass. Thorac Cardiovasc Surg. 1999;47:26–31[Medline]
  24. Kiziltepe U, Uysalel A, Corapcioglu T, Akan H, Akalin H. Effects of combined conventional and modified ultrafiltration in adult patients undergoing cardiac surgery. Ann Thorac Surg 2000 (in press).
  25. Houghton JL, Prisant LM, Carr AA, Flowers NC, Frank MJ. Racial differences in myocardial ischemia and coronary flow reserve in hypertension. J Am Coll Cardiol. 1994;23:1123–1129[Abstract]
  26. Houghton JL, Smith VE, Strogatz DS, Henches NL, Brieisblatt WM, Carr AA. Effect of African-American race and hypertensive left ventricular hypertrophy on coronary vascular reactivity and endothelial function. Hypertension. 1997;29:706–714[Abstract/Free Full Text]
  27. Chapman JN, Mayet J, Chang CL, Foale RA, Thom SA, Poulter NR. Ethnic differences in the identification of left ventricular hypertrophy in the hypertensive patient. Am J Hypertension. 1999;12:437–442[CrossRef][Medline]
  28. Laviest TA. Beyond dummy variables and sample selection: what health services researchers ought to know about race as a variable. Health Serv Res. 1999;29:1–16
  29. Richardson JV, Cyrus RC. Reduced efficacy of coronary artery bypass grafting in women. Ann Thorac Surg. 1986;42:S16–S21[Medline]
  30. Edwards FH, Carey JS, Grover FL, Bero JW, Hartz RS. Impact of gender on coronary bypass operative mortality. Ann Thorac Surg. 1998;66:125–131[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
P. L. DiGiorgi, F. G. Baumann, A. M. O'Leary, C. F. Schwartz, E. A. Grossi, G. H. Ribakove, S. B. Colvin, A. C. Galloway, and J. B. Grau
Mitral Valve Disease Presentation and Surgical Outcome in African-American Patients Compared With White Patients
Ann. Thorac. Surg., January 1, 2008; 85(1): 89 - 93.
[Abstract] [Full Text] [PDF]

Home page
 J. Am. Soc. Nephrol.Home page
S. S. Waikar, G. C. Curhan, J. Z. Ayanian, and G. M. Chertow
Race and Mortality after Acute Renal Failure
J. Am. Soc. Nephrol., October 1, 2007; 18(10): 2740 - 2748.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
A. N. Trivedi, T. D. Sequist, and J. Z. Ayanian
Impact of Hospital Volume on Racial Disparities in Cardiovascular Procedure Mortality
J. Am. Coll. Cardiol., January 17, 2006; 47(2): 417 - 424.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
J. S. Rumsfeld and A. J. Epstein
Racial Disparities in Cardiovascular Procedure Outcomes: Turn Down the Volume
J. Am. Coll. Cardiol., January 17, 2006; 47(2): 425 - 426.
[Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
A. Zacharias, T. A. Schwann, C. J. Riordan, S. J. Durham, A. Shah, and R. H. Habib
Operative and Late Coronary Artery Bypass Grafting Outcomes in Matched African-American Versus Caucasian Patients: Evidence of a Late Survival-Medicaid Association
J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1526 - 1535.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
S. H. Konety, M. S. Vaughan Sarrazin, and G. E. Rosenthal
Patient and Hospital Differences Underlying Racial Variation in Outcomes After Coronary Artery Bypass Graft Surgery
Circulation, March 15, 2005; 111(10): 1210 - 1216.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
N. E. Taylor, S. O'Brien, F. H. Edwards, E. D. Peterson, and C. R. Bridges
Relationship Between Race and Mortality and Morbidity After Valve Replacement Surgery
Circulation, March 15, 2005; 111(10): 1305 - 1312.
[Abstract] [Full Text] [PDF]

Home page
 J. Am. Soc. Nephrol.Home page
C. V. Thakar, S. Arrigain, S. Worley, J.-P. Yared, and E. P. Paganini
A Clinical Score to Predict Acute Renal Failure after Cardiac Surgery
J. Am. Soc. Nephrol., January 1, 2005; 16(1): 162 - 168.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
B. M. Rothenberg, T. Pearson, J. Zwanziger, and D. Mukamel
Explaining disparities in access to high-quality cardiac surgeons
Ann. Thorac. Surg., July 1, 2004; 78(1): 18 - 24.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
M. Prakash, S. Partington, V. F. Froelicher, P. A. Heidenreich, and J. Myers
The Effect of Ethnicity on Survival in Male Veterans Referred for Electrocardiography and Treadmill Testing
Arch Intern Med, October 13, 2003; 163(18): 2204 - 2210.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
C. R. Bridges
Cardiac surgery in African Americans
Ann. Thorac. Surg., October 1, 2003; 76(4): S1356 - 1362.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
W. A. Cooper, W. Brinkman, R. J. Petersen, and R. A. Guyton
Impact of renal disease in cardiovascular surgery: emphasis on the African-American patient
Ann. Thorac. Surg., October 1, 2003; 76(4): S1370 - 1376.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
J. S. Rumsfeld, M. E. Plomondon, E. D. Peterson, M. G. Shlipak, C. Maynard, G. K. Grunwald, F. L. Grover, and A. L. W. Shroyer
The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration
J. Am. Coll. Cardiol., November 20, 2002; 40(10): 1786 - 1793.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
A. Heiat, C. P. Gross, and H. M. Krumholz
Representation of the Elderly, Women, and Minorities in Heart Failure Clinical Trials
Arch Intern Med, August 12, 2002; 162(15): 1682 - 1688.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bridges, C. R.
Right arrow Articles by Coombs, L. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bridges, C. R.
Right arrow Articles by Coombs, L. P.

HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK