Racial differences in mortality in patients with advanced systolic heart failure: Potential role of right ventricular ejection fraction Michel White a, ⁎, Kanan Patel b , Guillem Caldentey a , Prakash Deedwania c , Raya Kheirbek d , Ross D. Fletcher d , Inmaculada B. Aban e , Alexander Lo e , Wilbert S. Aronow f , Gregg C. Fonarow g , Stefan D. Anker h , Ali Ahmed d a Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada b University of California, San Francisco, CA, USA c University of California, Fresno, San Francisco, CA, USA d Veterans Affairs Medical Center, Washington, DC, USA e University of Alabama at Birmingham, Birmingham, AL, USA f New York Medical College, Valhalla, NY, USA g Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, CA, USA h Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany abstract article info Article history: Received 24 March 2014 Received in revised form 16 September 2014 Accepted 20 September 2014 Available online 28 September 2014 Keywords: Race Heart failure Ejection fraction Mortality In Beta-Blocker Evaluation of Survival Trial (BEST) bucindolol significantly reduced mortality among Cau- casians with systolic heart failure (HF) but not among African Americans. Whether this differential effect can be explained by racial differences in baseline characteristics has not been previously examined. Of the 2708 BEST participants, 627 were African Americans. Because African Americans were more likely to be younger and women, we used age–sex-adjusted hazard ratios (HR) and 95% confidence intervals (CI) to estimate their outcomes (vs. Caucasians). A step-wise multivariable-adjusted model using 24 baseline characteristics was used to identify variables associated with between-race outcome differences and pro- pensity-matching was used to determine independence of associations. Age–sex-adjusted HR for all-cause mortality for African Americans during 2 years of mean follow-up was 1.27. African Americans were more likely to have lower right ventricular ejection fraction. African Americans had no association with mortality among propensity-matched patients. The higher risk of death among African Americans in BEST may in part be due to their lower RVEF which may in part explain the lack of response to bucindolol among these patients. Future studies need to examine the role of low RVEF on the effect of beta-blockers in pa- tients with systolic HF. © 2014 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Population-based studies have suggested that African American patients with heart failure (HF) have a higher mortality rate than Cauca- sians with the same condition [1]. This finding has been attributed to differences in the severity, causes and management of HF, the preva- lence of coexisting conditions and, also to socioeconomic factors [2,3]. Moreover, in equally treated patients it has been shown that racial dif- ferences may still exist [4]. Whether differences in the cardiac intrinsic or modulated functions or response to drug treatment contribute to these disparities has been incompletely assessed. In fact, African- American patients with HF respond less to angiotensin modulating agents [5] while the use of a direct vasodilator treatment with the combination of hydralazine–nitrates has shown to be effective in these patients [6–8]. Although bucindolol had no overall mortality benefit in the Beta- Blocker Evaluation of Survival Trial (BEST), in a subgroup analyses, Caucasian patients exhibited a significant survival benefit to treatment while African-American yielded no significant differences in mortality (P for interaction, 0.02) [9]. Whether these results could be related to chance or a decreased effectiveness of beta-blockers in African American patients remains unanswered [10]. Furthermore, whether if this racial difference in response to bucindolol therapy can be explained by racial differences in baseline characteristics has not been previously examined. In particular, the BEST was unique among beta-blocker trials in HF because data on right ventricular ejection function (RVEF) were collected. Therefore, the objective of present study is to determine the association between race and outcomes in the BEST, and examine if International Journal of Cardiology 177 (2014) 255–260 ⁎ Corresponding author at: Université de Montreal, Montreal Heart Institute, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada. Tel.: +1 514 376 3330; fax: +1 514 376 0173. E-mail address: m_white@icm-mhi.com (M. White). http://dx.doi.org/10.1016/j.ijcard.2014.09.094 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard