Racial differences have recently been described in hospital practice, most notably with regard to cardiac procedure utilization. To evaluate the possible reasons behind these differences, we analyzed statistics generated from a surgical referral conference at a large, tertiary care Veterans Affairs hospital between the years 1988 and 1996. In this setting, there is no financial incentive for physicians to recommend or perform invasive procedures, as all physicians are salaried employees of the Veterans Administration. Furthermore, all patients presented at conference have already had cardiac catheterization and are felt to be potential candidates for surgery or angioplasty. Cardiac therapeutic procedures (surgery or percutaneous transluminal coronary angioplasty) were recommended for 1075 of 1474 (72.9%) Caucasian patients and 207 of 322 (64.3%) African-American patients (odds ratio 1.497, 95% confidence interval 1.160 to 1.932, p = 0.0022). Of those patients presented with the option of an invasive procedure, 32 of 207 (15.4%) African-American patients and 89 of 1075 (8.3%) Caucasian patients refused any invasive procedure (odds ratio 2.026, 95% confidence interval 1.311 to 3.130, p = 0.0025). We conclude that reluctance by African-American patients to undergo invasive cardiac procedures may help explain observed disparities in race-related cardiac care.