[Skip to Content]
[Skip to Content Landing]
April 10, 1996

Influence of Race, Sex, and Age on Management of Unstable Angina and Non—Q-Wave Myocardial Infarction: The TIMI III Registry

Peter H. Stone, MD; Bruce Thompson, PhD; H. Vernon Anderson, MD; et al Marvin W. Kronenberg, MD; Robert S. Gibson, MD; William J. Rogers, MD; Daniel J. Diver, MD; Pierre Théroux, MD; J. W. Warnica, MD; James B. Nasmith, MD; Catherine Kells, MD; Neal, MD; Carolyn H. McCabe; Mark Schactman, MS; Genell L. Knatterud, PhD; Eugene Braunwald, MD; Christopher P. Cannon, MD; Joyce Depkin; Martha Canner, MS; Patricia Wilkins; Rosemary Giro; Neal Kleiman, MD; Marilyn J. Francis, RN; Kay Yang, RN; Nancy Cummings, RN; Donald S. Balm, MD; Joseph Carozza, MD; Susan Marble, MS, RN; Ann Slater, RN; Donald Pallsaltis, MD; Ginette Gaudette, RN; Thomas L. Shook, MD; Carolyn Gray, RN; Pierre De Guise, MD; Johanne Levesque, RN; Marie-Andrée Séguin; Faryala Shabani, MD; Peter Mahrer, MD; Joni Noceda, RN; Judy Fletcher, RN; Bernard Chaitman, MD; Frank Aquirre, MD; Leslie Miller, MD; Morton Kern, MD; Robert Weins, MD; Arthur Labovitz, MD; Lawrence Lewis, MD; Glenda Haas, RN; Judith Hochman, MD; Anthony Pepe, MD; Mary McAnulty, RN; Deborah Tormey, RN; William A. Baxley, MD; Larry S. Dean, MD; Vera A. Bittner, MD; Louis J. Dell'Italia, MD; Jerri Moody, RN; Cynthia Weeks; J. Wayne Warnica, MD; E. R. Smith, MD; D. G. Wyse, MD; M. L. Knudtson, MD; Christine Hall, RN; Terry Churchill-Smith, RN; Ted Feldman, MD; Matthew J. Sorrentino, MD; Anne Pastoret, RN; Sharon Holloway, RN, MSN; Marcus Williams, MD; Gregory J. Dehmer, MD; David A. Tate, MD; Mary Jackson, RN, MSN; James T. Willerson, MD; H. V. Anderson, MD; Louise Jones, RN; Lynette Weigelt, RN; Michael J. Davis, MD; Robert W. Farrell, MD; M. Amir Ibrahim, MD; John F. Schmedtje Jr, MD, MPH; Eric R. Powers, MD; Sharon L. Sayre, BSN; Nancy M. Fauber, MSN; Catherine M. Kells, MD; David Johnstone, MD; Theresa Fawcett, RN; Vivian Nedelcu
Author Affiliations

From the Cardiovascular Division (Dr Stone) and the TIMI III Registry Study Chairman's Office (Drs Stone and Braunwald and Ms McCabe), Brigham and Women's Hospital, Boston, Mass; the TIMI III Registry Data Coordinating Center, Maryland Medical Research Institute, Baltimore (Drs Thompson and Knatterud and Mr Schactman); and the Departments of Medicine at Baylor College of Medicine, Houston, Tex (Dr Kleiman); Harvard University/Beth Israel Hospital, Boston, Mass (Dr Diver); Hôpital du Sacré-Coeur de Montréal (Quebec) (Dr Nasmith); Institut de Cardiologie de Montréal (Quebec) (Dr Théroux); University of Alabama at Birmingham (Dr Rogers); University of Calgary (Alberta)/ Foothills Hospital (Dr Warnica); University of Texas Health Science Center at Houston (Dr Anderson); University of Texas Medical Branch at Galveston (Dr Kronenberg); University of Virginia, Charlottesville (Dr Gibson); and Victoria General Hospital, Halifax, Nova Scotia (Dr Kells).
TIMI III Registry Study Chairman's Office; TIMI III Registry Data Coordinating Center; TIMI III Registry ECG Core Laboratory; TIMI HI Registry Clinical Centers Baylor College of Medicine; Brigham and Women's Hospital; Harvard University/Beth Israel Hospital; Hopital du Sacre-Coeur de Montreal; The Hospital of the Good Samaritan; Institut de Cardiologie de Montreal (Montreal Heart Institute); Kaiser Permanente Medical Center; St Louis University Meditai Center; St Lukes/Roosevelt Hospital Center (Columbia University); University of Alabama at Birmingham; University of Calgary/Foothills Hospital; University of Chicago Hospitals; University of North Carolina; University of Texas Health Science Center at Houston; University of Texas Medical Branch at Galveston; University of Virginia; Victoria General Hospital

JAMA. 1996;275(14):1104-1112. doi:10.1001/jama.1996.03530380046030

Objective.  —To investigate the natural history and response to treatment of patients with unstable angina or non—Q-wave myocardial infarction (MI).

Design.  —Inception cohort.

Setting.  —Patients in general community, primary care, or referral hospitals.

Patients.  —All patients with an episode of unstable exertional chest pain or chest pain at rest presumed to be ischemic in origin lasting 5 minutes or more but without persisting ST-segment elevation greater than 30 minutes or the development of Q-waves were identified and enumerated in 18 participating hospitals. A subset of enumerated patients was selected to be followed prospectively using specific sampling strategies that would provide adequate numbers of black, women, and elderly (aged ≥75 years) patients for comparison with their respective counterparts. Main Outcome Measures.—The primary analysis compared the incidence of death or Ml at 42 days after entry into the prospective study according to race, sex, and age. Other outcomes considered were recurrent ischemia and the combined outcomes of death, Ml, or recurrent ischemia by 42 days after entry.

Results.  —A total of 8676 admissions with unstable angina or non—Q-wave Ml were enumerated and, of these, 3318 patients were selected for the prospective study. The direct adjusted mean age of the 3318 patients was 63.8 years. There were 943 blacks and 2375 nonblacks. Compared with nonblacks, blacks were less likely to be treated with intensive anti-ischemic therapy for their qualifying anginal episode and less likely to undergo invasive procedures (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.58 to 0.72; P<.001). However, of those who underwent angiography (45% of blacks and 61% of nonblacks), blacks had less extensive and severe coronary stenoses than nonblacks. The incidence of death and MI was similar for blacks and nonblacks, but blacks had a lower incidence of recurrent ischemia. There were 1678 men and 1640 women. Women were less likely than men to receive intensive anti-ischemic therapy and less likely to undergo coronary angiography (RR, 0.71; 95% CI, 0.65 to 0.78; P<.001). Women had less severe and extensive coronary disease and were less likely to undergo revascularization, yet had a similar risk of experiencing an adverse cardiac event by 6 weeks. There were 2490 patients aged 75 years or less and 828 patients aged more than 75 years. Elderly patients received less aggressive anti-ischemic therapy and were less likely to undergo coronary angiography than their younger counterparts. Elderly patients had more severe and extensive coronary disease but fewer revascularization procedures than younger patients and experienced a much higher incidence of adverse cardiac events both in hospital and by 6 weeks.

Conclusions.  —Among patients presenting with acute ischemic chest pain without persistent ST-segment elevation, blacks appeared to have less severe coronary disease, received revascularization less frequently, and had less recurrent ischemia compared with nonblacks. Women also were found to have less severe coronary disease and were treated less intensely than men, but experienced similar outcomes. Elderly patients had more severe coronary disease than younger patients on coronary angiography, but were more likely to be treated medically, and they experienced far more adverse outcomes. These data suggest that more aggressive strategies should be directed to those patients with the greatest likelihood of adverse outcomes.(JAMA. 1996;275:1104-1112)