Racial disparity seen in stroke-preventing surgery

NEW YORK (Reuters Health) - Minorities are at greater risk of complications from surgery to remove blockages from the neck arteries, and are more likely than whites to have the procedure in appropriate cases, a new study finds.

The surgery, known as carotid endarterectomy, removes blockages from the carotid (neck) arteries supplying the brain, with the goal of preventing future strokes.

However, the procedure carries its own risks -- which include causing a stroke -- and for some people with carotid blockages, the potential risks outweigh the possible benefits.

In the new study, reported in the journal Stroke, researchers found that compared with whites, black and Hispanic patients were more likely to have a carotid endarterectomy in inappropriate instances.

And overall, their rates of serious complications were higher.

Past research has shown that minorities are less likely to have a carotid endarterectomy when it is an appropriate option.

Coupled with these latest findings, it seems minorities face a "triple whammy" of underuse, overuse and greater complication risks, lead researcher Dr. Ethan A. Halm, of the University of Texas Southwestern Medical Center in Dallas, told Reuters Health in an interview.

Halm and his colleagues based their findings on nearly 9,100 Medicare patients who had endarterectomies performed in New York State hospitals.

Nearly 18 percent of Hispanic patients had the procedure inappropriately, as did 13 percent of African Americans. That compared with 8 percent of white patients.

The disparity was seen only among patients whose carotid blockages had never caused symptoms - that is, previous strokes or "mini-strokes" known as transient ischemic attacks. In most inappropriate cases, patients were both symptom-free and had co-existing health problems -- such as high blood pressure, heart disease and diabetes - which meant that surgical risks likely outweighed the potential benefits.

When it came to overall complication rates, Halm's team found that 7 percent of African Americans and 9.5 percent of Hispanics died or suffered a stroke within 30 days of surgery. That rate was roughly 4 percent among white patients.

For black patients, the disparity in complications appeared to be largely related to poorer overall health and the fact that they were more likely than whites to have a less-experienced surgeon.

The reasons for Hispanic patients' higher complication rate were not clear.

More research is needed to understand the reasons for the disparities and how to best overcome to them.

But for now, patients can take some steps for themselves, according to Halm. If they are concerned about whether a carotid endarterectomy is appropriate for them, getting a second opinion from another surgeon or neurologist is a good idea.

This is most important for people who are free of symptoms, Halm explained. "If you're asymptomatic, it is not an emergency situation, and people shouldn't feel rushed. They have time to gather more information."

As for minimizing the risk of complications, Halm suggested that patients -- symptom-free or not -- ask their surgeon about his or her complication rate and the number of carotid endarterectomies he or she has done in the past year (an indicator of experience).

According to standard guidelines, Halm said, the rate of death or stroke within 30 days should be no higher than 6 percent for symptomatic patients, and no higher than 3 percent for asymptomatic patients.

When it comes to a surgeon's experience, those who perform at least 30 to 40 endarterectomies a year have better outcomes, on average.

SOURCE: Stroke: Journal of the American Heart Association, July 2009.