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Racial differences in outcome in the Multicenter UnSustained Tachycardia Trial (MUSTT): a comparison of whites versus
Andrea M Russo1, Gail E Hafley, Kerry L Lee
1University of Pennsylvania Health System, Presbyterian Medical Center, Philadelphia, PA 19104, USA. andrea_russo@uphs.upenn.edu
Insights
Race influenced outcomes in the MUSTT trial. Electrophysiologically-guided therapy benefited whites but not blacks, partly due to higher implantable cardioverter-defibrillator use in whites.
Area of Science:
- Cardiology
- Clinical Electrophysiology
- Health Disparities
Background:
- The Multicenter UnSustained Tachycardia Trial (MUSTT) established implantable cardioverter-defibrillators (ICDs) benefits for coronary disease patients with reduced ejection fraction.
- Prior research indicates racial disparities in sudden cardiac death risk among ischemic heart disease patients.
Purpose of the Study:
- To investigate the impact of race on the outcomes of the MUSTT trial.
- To analyze how race influences the effectiveness of electrophysiologically-guided therapy and ICD implantation.
Main Methods:
- Analysis of the Multicenter UnSustained Tachycardia Trial (MUSTT) data.
- Comparison of outcomes based on race (White vs. Black) and treatment assignment (EP-guided vs. no EP-guided therapy).
Main Results:
- White patients had higher rates of prior revascularization and inducible ventricular arrhythmias compared to Black patients.
- Electrophysiologically (EP)-guided therapy reduced arrhythmic death/cardiac arrest and total mortality in Whites, but not in Blacks.
- Black patients receiving no EP-guided therapy showed better survival than those receiving EP-guided therapy, potentially linked to lower ICD implantation rates in Black patients.
Conclusions:
- Race significantly influenced trial outcomes and the benefit derived from EP-guided therapy.
- Differences in ICD implantation rates, arrhythmic substrates, and proarrhythmic responses to antiarrhythmic drugs may explain the observed racial disparities in outcomes.
Background:
The Multicenter UnSustained Tachycardia Trial (MUSTT) demonstrated the benefit of implantable cardioverter-defibrillators (ICDs) in patients with coronary disease, asymptomatic nonsustained ventricular tachycardia, and reduced left ventricular function. Previous studies have shown racial differences in risk of sudden death in patients with ischemic heart disease.
Methods And Results:
We analyzed the influence of race on results of MUSTT. Whites were more likely to have prior revascularization and inducible, randomizable sustained ventricular arrhythmias and less likely to have left ventricular hypertrophy than were blacks. Compared with blacks, whites randomly assigned to electrophysiologically (EP)-guided therapy had a lower risk of arrhythmic death/cardiac arrest (adjusted P=0.003) and lower total mortality rates (adjusted P=0.051). In contrast, there was no racial difference in the risk of arrhythmic death/cardiac arrest among patients randomly assigned to no EP-guided therapy (adjusted P=0.477). Among whites, EP-guided therapy resulted in a survival benefit compared with no EP-guided therapy. However, survival of blacks randomly assigned to no EP-guided therapy was better than blacks receiving EP-guided therapy. This difference is partially explained by a higher ICD implantation rate in whites versus blacks (50% versus 28%, P=0.034). Whites were more likely to remain inducible after serial EP-guided drug testing (67% versus 42%, P=0.011), making them more likely to become eligible for ICDs.
Conclusions:
The outcome in this trial and the benefit of EP-guided therapy appeared to be influenced by race. In addition to differences in ICD implantation rates, differences in arrhythmic substrates and proarrhythmic responses to antiarrhythmic drugs may have influenced outcome.
