Intersectionality of inequalities in revascularisation and outcomes for acute coronary syndrome in England: nationwide linked cohort study.

Background: Inequalities in access to care for women, people of non-white ethnicity, who live in areas of social deprivation, and with multiple long-term conditions lead to inequity of outcomes. We investigated the intersectionality of these causes of health inequality on coronary revascularisation and clinical outcomes for admissions with acute coronary syndrome (ACS).

Methods: We included hospital admissions in England for types of acute coronary syndrome from April 2015 to April 2018 and linked Hospital Episode Statistics to the Office for National Statistics mortality data. The primary outcome was time to all-cause mortality. Time-to-event analyses examined the associations of sex, ethnicity and socioeconomic deprivation with revascularisation.

Results: Of 428 700 admissions with ACS, 212 015 (48.8%) received revascularisation within 30 days. Women, black ethnicity, multimorbid and frail patients were less likely to undergo revascularisation. South Asian ethnicities had higher (HR = 1.15, 95% CI 1.14-1.17) revascularisation rates and comparable risk-adjusted survival but higher re-admission rates when compared to other ethnic groups. Women had higher 1-year all-cause (25.5% vs 14.7%-STEMI; 24.9% vs 18.7%-NSTEMI) and cardiovascular (22.6% vs 13.2%-STEMI; 20.3% vs 15.6%-NSTEMI) mortality than men. After adjusting for confounders, women had a lower all-cause mortality when compared to men.

Conclusions: Outcomes attributed to women and people of South Asian ethnicity may be attributable to age, comorbidity and frailty at presentation. Black ethnicity, geography and social deprivation may be sources of inequality. These findings highlight the unmet need and may provide potential targets for interventions that address inequalities.