Is coronary angiography underused in an inner-city population?

We sought to determine, prospectively, if any race or sex disparities in coronary angiography use was explained by standardized criteria for the procedure.

We prospectively identified 153 patients > or =40 years of age who underwent evaluation for coronary disease from December 1998 to November 1999 at a municipal hospital. Patients requiring angiography were referred to a nearby academic facility. Information abstracted from medical records was used to assess appropriateness of management and clinical outcomes. Physician reviewers used RAND criteria to rate the appropriateness and necessity for angiography. Multivariate logistic regression models determined predictors of angiography.

Blacks and Hispanics made up 78% of patients, and proportions of men and women were similar. The patients' mean age was 58.4 years (+/- 10.4). The most frequent indication for angiography was atypical chest pain (32.7%). Approximately two thirds of the population had two or more coronary risk factors (such as diabetes and hypertension). Angiography was rated necessary for 75% (n=77) of patients; of these, 66.2% had the procedure. Among those undergoing angiography, two thirds had clinical disease (> or =50% stenosis of a major vessel). In multivariate logistic regression models, urgent indications, such as post-myocardial infarction angina or exacerbation of angina, were the strongest predictors for angiography (odds ratio 3.9, 95% confidence interval 1.7-9.1]). During the 18 months of follow-up, no deaths were seen among the medically treated patients for whom angiography was rated necessary (n=26).

Angiography was underused in this publicly insured population. Improved access to coronary angiography among minority populations with multiple coronary risk factors is still needed.