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Racial disparity in use of clot-busters for stroke 'alarming'

DALLAS, May 4 – Whites are five times more likely than blacks to receive emergency clot-dissolving therapy for stroke, according to a review of records at 42 U.S. academic medical centers, researchers report in the May issue of Stroke: Journal of the American Heart Association.

Among 1,195 stroke patients, just 49 individuals (4.1 percent) received the drug tPA – the only Food and Drug Administration-approved clot-buster for stroke. Use in African-Americans lagged far behind whites. Of the 285 blacks in the study, only three (1.1 percent) received tPA compared with 42 (5.3 percent) of the 788 whites in the study. The disparity persisted after statistical adjustment for differences in age, gender, type of insurance, and stroke severity.

“Though a more detailed analysis of factors predicting treatment is required, we have to consider the possibility that racism is contributing. If we can’t acknowledge the possibility that racism may be playing a role, we may never be able to correct disparities in health care,” says a study author, S. Claiborne Johnston, M.D., MPH, assistant professor of neurology at the University of California, San Francisco.

An accompanying editorial urges healthcare professionals to pay serious attention to the results, particularly because African-Americans have a greater risk of stroke than whites and are more likely to die from stroke.

“It is alarming to learn that racial disparity can have an impact on the opportunity to receive intravenous tPA,” writes David Z. Wang, D.O., director of the OSF Stroke Network and clinical assistant professor of neurology and clinical pharmacology at the University of Illinois College of Medicine at Peoria.

Blacks were less likely to receive thrombolytics in all regions of the country except the Southeast, where rates were similar. In the Northeast, 2.3 percent of whites received tPA, while less than one percent of blacks did. In the Midwest and West, the rates were 4.8 percent and 3 percent for whites compared to 2.1 percent and 1 percent for blacks.

In general, researchers found low use of tPA for all patients. Among all patients who arrived at the hospital within two hours of symptom onset – an ideal group for tPA – fewer than a quarter received the drug.

Sidney Smith, M.D., chief science officer of the American Heart Association states: “It is reassuring that in the Southeast region, African-American and white patients appear to receive a similar rate of treatment. Perhaps this region can serve as an example for the rest of the country to identify effective approaches to the treatment of this devastating disorder.”

Smith said the findings are of concern because overall, few patients eligible for thromobolytic therapy received it and of those, African-Americans and the uninsured were less likely to receive it.

There are some reasons not to administer tPA, such as strokes caused by a bleeding blood vessel, or patients arriving too late to emergency rooms. But these reasons did not account for the racial disparity, researchers say.

The drug is currently indicated for treatment of ischemic stroke patients who can be treated within three hours of symptom onset. Researchers found that though African-American patients generally took slightly longer to reach the hospital, it was not a significant time difference.

A large number of patients in the study could not receive tPA because of the time delay or other conditions that made treatment unsafe. But when the analysis was limited to 189 patients who were excellent candidates for tPA, 8.3 percent (3 of 36 individuals) of qualified black patients received the clot-dissolving therapy compared to 24.6 percent (34 of 138 individuals) of white patients. No black patients were documented to have refused the treatment, while three whites did.

The overall low use of the drug was especially surprising because the study involved academic medical centers, which presumably would have the most experience with thrombolytic therapy for stroke, Johnston says. In addition, researchers reviewed the records of patients treated between June and December 1999 – three years after tPA was approved.

The drug is associated with an increased chance of bleeding into the brain, and this makes some physicians uncomfortable and more resistant to using the drug, Johnston says. However, he notes, “Even though there is an increased risk for a small subpopulation of patients, the majority of patients will benefit from treatment with tPA.”

Researchers were uncertain whether concern for hemorrhage risk could be contributing to the difference in use between blacks and whites.

“While further research may help us understand more specifically the racial disparity in stroke care, an education effort should take place immediately to identify and offer IV tPA to appropriate black stroke patients at all healthcare institutions,” Wang writes.

The American Heart Association, and its division the American Stroke Association, have recently identified ethnic differences in cardiovascular disease as a high priority and plan to initiate programs to address these issues. Through the program Operation Stroke, which is underway in more than 75 communities throughout the country, the association is helping patients identify the symptoms of stroke and learn the importance of getting to the hospital quickly.

Co-authors are Lawrence H. Fung, B.A.; Leslie A. Gillum, M.D.; Wade S. Smith, M.D., Ph.D.; Lawrence M. Brass, M.D.; Judith H. Lichtman, Ph.D.; and Andrew N. Brown, M.D., MPH. The work was funded in part by the National Institutes of Health.

CONTACT: For journal copies only,
please call: 214-706-1396
For other information, call:
Carole Bullock: 214-706-1279 caroleb@heart.org
Bridgette McNeill: 214-706-1135

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