Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy

Background and Purpose-We sought to determine whether there are racial diff erences in use of carotid artery imaging after controlling for clinical fac tors and to ascertain racial differences in presenting signs and symptoms a nd overall appropriateness for carotid endarterectomy (CE), Methods-We performed a retrospective cohort study of 803 patients older tha n 45 years, hospitalized between 1991 and 1994 at any of 4 Veterans Affairs Medical Centers, with a discharge diagnosis of transient ischemic attack o r ischemic stroke. Clinical data were abstracted from the medical record, i ncluding presenting symptoms, diagnostic test results, and use of surgical procedures. Appropriateness for CE was determined according to RAND criteri a. Results-Black patients were more likely than white patients to present with stroke (78% versus 55%) but less likely to present with transient ischemic attack (22% versus 45%; P=0.001), There was no racial difference in medica l comorbidity or preoperative risk. Black patients were less likely to have an imaging study of their carotid arteries (67% versus 79%; P=0.001). Race remained an independent predictor of imaging after adjustment for clinical factors (odds ratio=1.50; 95% CI, 1.06 to 2.13), Because of higher prevale nce of significant carotid artery stenosis, whites were significantly more likely than blacks to be assessed as appropriate candidates for surgery wit h the use of RAND criteria (18% versus 4%; P=0.001). Conclusions-Use of carotid artery imaging, a critical step in determining e ligibility for CE, is influenced by the patient's race after controlling fo r clinical presentation. Adjustment for appropriateness of CE reduces but d oes not eliminate the importance of race.